Penn State Office of the University Registrar

Leave of Absence Form

Please fill out this online form, print (using "Print Form" button at bottom of page),
sign and submit the form to your College dean.

** Deadline Notice: This form must be submitted by the Friday before the first day of classes. **

Permanent Residence:
I elect to take a leave of absence:
Start Semester:
Return Semester:

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: _____________________________________ Date: ___________________

Signature of Dean
(or campus representative): ______________________________ Date: ___________________


Office Use Only:

Revised 9/6/17