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Summary: GRADUATE DIVISION UNIVERSITY OF CALIFORNIA, SANTA BARBARA
REQUEST FOR A LEAVE OF ABSENCE
See the Leave of Absence Information sheet at: http://www.graddiv.ucsb.edu/academic/petitions/LOA.htm
Name ____________________________________________________________ Perm # ___________________
Phone ____________________ E-mail__________________________________ Dept. _____________________
(International students only) Visa Status ______ I will be residing in ________________________________________ while on leave.
City/State/Country
*Note: International students in a F1 or J1 visa category are required to make an appointment with Office of International Students
before requesting a family emergency leave of absence.
I request a leave for the following quarter(s): Fall _______ Winter _______ Spring _______
year year year
I have fellowship funding: Yes No Source: _________________________________
Central Fellows must also complete the Request for Change in Fellowship Schedule form
Check box for leave category and supply documentation requested:
MEDICAL (attach doctor's note) PARENTING (attach birth certificate) MILITARY (attach orders)
FAMILY EMERGENCY (describe)
Explanation of request:
FILING FEE quarter (terminal degrees only requires Research Advisor's signature in this box.)
I concur that this student will be able to file during the quarter for which this leave is requested.
______________________________________________________________ Date _______________________
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