On-Leave Form

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

Check if same as above

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