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Spring quarter/semester Fall trimester Winter trimester Summer quarter (if mandatory) Spring trimester (if mandatory) Indicate exact dates for which you are requesting a Leave of Absence: From: To: 12. Briefly state your reason(s) for a leave of absence: (please print or type attach additional pages or documentation if necessary) IV. STUDENT S SIGNATURE (YOU MUST SIGN AND DATE THIS FORM) 13. Signature (I certify to the best of my kno.

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