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Get Application For Leave Of Absence/total Withdrawal - Poly

Atures have been obtained. Date of final approval determines the date for refund calculation. Note: Leave of Absences are only approved on a semester basis with a maximum of 2 semesters at any one time. POLY ID# Academic Department: Last Name PART TIME FULL TIME First Name Address LEAVE OF ABSENCE UNDERGRADUATE GRADUATE Telephone City TOTAL WITHDRAWAL INTERNATIONAL STUDENT? YES NO CURRENTLY REGISTERED? YES NO State Email Address Postal Code EFFECTIVE DATE: semester year RETURN D.

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