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OUR Revised LOA Form May 23 2002 UNIVERSITY OF THE PHILIPPINES OPEN UNIVERSITY Office of the University Registrar APPLICATION FOR LEAVE OF ABSENCE LOA FORM NAME OF STUDENT STUDENT NUMBER PROGRAM/MAJOR LEARNING CENTER TERM OF EFFECTIVITY REASON FOR FILING LOA FEE PAID UNDER OR DATED IN THE AMOUT OF SIGNATURE OF STUDENT Tutor s signature over printed name Date Noted LC Coordinator IMPORTANT 1 A student may apply for LOA before the 3rd tutorial for a 4-study session or the 4th tutorial for a 5-study session. 2 LOA must not exceed one year from the term of effectivity. DO NOT FILL THIS PORTION. NOTE TO THE FACULTY-IN-CHARGE If the application for Leave of Absence is filed after the 2nd tutorial for a 4-study session or the 3rd tutorial for a 5-study session you must indicate the standing of the student at the time the leave is applied for. After filling up this portion please submit this to the Office of the Faculty Dean* Subjects Enrolled in Class Standing Passing or Failing FIC s Signature APPROVED DEAN DATE. 2 LOA must not exceed one year from the term of effectivity. DO NOT FILL THIS PORTION. NOTE TO THE FACULTY-IN-CHARGE If the application for Leave of Absence is filed after the 2nd tutorial for a 4-study session or the 3rd tutorial for a 5-study session you must indicate the standing of the student at the time the leave is applied for. After filling up this portion please submit this to the Office of the Faculty Dean* Subjects Enrolled in Class Standing Passing or Failing FIC s Signature APPROVED DEAN DATE.

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