Academic Leave of Absence Form

An undergraduate student whose enrollment at the University is interrupted for one or more semesters must make application for re-admission, unless an approved leave of absence has been granted. A leave of absence is granted for one semester only. If academic or disciplinary suspension occurs prior to the effective date of the leave, the leave of absence is automatically canceled.

First Name:	Middle Initial:
Last Name:	Campus ID:
Major(s):
Mailing Address:
City:
State:	Zip Code:
UWO E-mail Address:	Phone:
E-mail Address during leave:
Semester on Leave of Absence: Spring Fall	Year:
Reason for Leave of Absence: (select one) Study Abroad in program offered by: (institution) in (country) Internship* offered by: (academic dept./company) *College of Business students must contact Jessica Pondell (424-3032) or pondellj@uwosh.edu. All others should contact Chrissy Lambie (424-2044) or lambiec@uwosh.edu for written approval of internship. Do you receive financial aid (student loans, grants, scholarships)? Yes No By checking this box, I verify that I have read the above information, understand it, and certify that the information provided by me is true.