Student Exchange Program
Permission for Leave Form
Student name _________________________________
Student number ______________
Major _______________________________________
Minor ______________________
Advisor ______________________________________
Date _______________________
Mr. / Ms. _____________________________is leaving on an exchange program to
________________ ___________________________________ for the _____________ semester/s
(name of host university/institution and country)
of the __________ Academic Year.
The above named student has requested permission to leave on an exchange program. Has the
student completed all obligations to you? If yes, check and sign; if not, write the obligations in the
space provided and sign.
1.
Registrar’s Office
____________________ Yes ( ) No ( ). Date: ________
2.
Librarian
____________________ Yes ( ) No ( ). Date: ________
3.
Finance Office
____________________ Yes ( ) No ( ). Date: ________
4.
Advisor
____________________ Yes ( ) No ( ). Date: ________
5.
Chairperson
____________________ Yes ( ) No ( ). Date: ________
6.
Dean
____________________ Yes ( ) No ( ). Date: ________
Obligations not met by student: ________________________________________________________
The attached list of transferable courses is an integral part of this application.
I, _______________________, have read and understood the BU “Student Exchange Policy” and I
am willing to comply with it.
____________________________
_________________
(Date)
(Student’s Signature)
____________________________
(AAVP’s Signature)
_________________
(Date)
cc: - Student, Advisor, Registrar, Dean/ Chairperson, External Academic Relations Office
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Student Exchange Program
List of Transferable Courses
Student name _________________________________
Student number ______________
Host University:_______________________________
Country_____________________
Semester(s):___________________________________
The following courses will be taken by the student at the host University and will be waived upon
his/her return to BU, subject to BU “Credit Transfer Policy”.
Courses at host university
Number and Title
Equivalent Course at BU
Credits
Number and Title
Credit s
Upon completing the exchange program, it is the responsibility of the student to inform the
Academic Office in writing at least two weeks before the semester begins about his/her intention to
return to BU and to transfer the courses taken at the host university/institution.
____________________________
(Advisor’s Signature)
_________________
(Date)
____________________________
(Chair’s Signature)
_________________
(Date)
____________________________
(Dean’s Signature)
_________________
(Date)
______________________________
_________________
(Student’s Signature)
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(Date)
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