UEWM Break Request Request Form
(Leave of Absence Form)

Fields marked (*) are required

Term for break:

Year: 2024, Semester * Spring Summer Fall

Student's Information

Immigration Status * U.S. Citizen Permanent Resident F1 Visa Student
Student's Name * ,
Phone *
No spaces or brackets e.g. 9999999999 Your mobile number is valid
Email *
Please enter a valid email address e.g. swapnil@example.com Your email address is now valid
Student ID * (If you don't have student ID, please enter: 0)
Financial Aid Student No Yes

Cleared Fee * Yes No
(Note: If found that your fee is still not cleared, the registrar reserves the right to cancel your application)

Reason for the break *

Please read and check the agreement

I hereby certify that all information provided by me on this form is accurate and I have read, and I understand the Leave of Absense instruction provided by the UEWM office.