Please review your entries on this form. If all of the information is entered correctly, please print (using "Print Form" button at bottom), sign and submit the form to your College dean.
Student Signature: _____________________________________
Signature of Dean
(or campus representative): ______________________________
Note: While on leave you can request a continuation of your Penn State access account by filling out the Penn State Access Account Extension for Student Leave or Absence Form. There is a fee for this continued service which is explained on the form.