University of Oregon Request For On-Leave Status 170 Susan Campbell Hall
Graduate School   (541) 346 5129

Note: All fields marked with an asterisk (*) are optional.

 

Last Name First Name
Student ID Student Type
Major Visa Type*
UO Email


Current Mailing Address  

Street 1 Street 2*
City State
Zip Valid Until
mm/dd/yyyy


Address While On-Leave

Street 1 Street 2*
City State
Zip Valid Until
mm/dd/yyyy


On-Leave Status Requested For:
 
Term of Return From On-Leave:



Year of Return:
 
Reason For Request (please note the department will be able to see the reason indicated but will not be granted access to any supporting documentation uploaded):