Submitted Wednesday, May 31, 2023 

Important: Please read the information below before completing the  form.

In order to adhere to federal regulations of the Department of Education, this leave of absence, together with any additional leaves of absence must not exceed a total of 180 days in any 12 month period. The 12 month period begins on the initial date of your LOA. If you have not returned at the end of the 180 day period, the university is required to notify the Department of Education of your last date of attendance. This will affect your Federal Financial Aid and your loan repayment status.

Students should be aware that dissertation/thesis chair assignments in place prior to taking a leave of absence are not guaranteed upon their return.  Questions about chair assignments should be directed to docadvisor@captechu.edu.

If you receive financial aid, you must meet with a Financial Aid advisor to discuss possible expiration of your federal student loan grace period and loan repayment terms. 

Failure to return to school after the leave of absence will constitute a withdrawal from the University. 

Only students in good standing with the University may take a leave of absence.

First Name:

Last Name:

Student ID:

Daytime Phone:

Email:

Last course completed:

Semester for leave of absence to begin:

Year for leave of absence to begin:

Semester for return from leave of absence:

Year for return from leave of absence:

Reason for Leave of Absence:

Additional explanation for LOA:

Are you a financial aid recipient?:

Are you receiving veterans educational benefits?: