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Request To Return From Leave of Absence: Division of Enrollment Services

This document is a request form for students returning from a leave of absence at Cleveland State University. It contains several sections for students to complete depending on their student type and academic status. Section A determines if a student needs to reapply based on attendance at other institutions. Section B checks for academic dismissal requiring a petition. Section C acknowledges the student's catalog rights will update. Section D discloses criminal charges or dismissals. Section E provides residency information. Section F collects contact and signature. The form requires disclosure of academic and legal issues during the leave for consideration of readmission.

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78 views1 page

Request To Return From Leave of Absence: Division of Enrollment Services

This document is a request form for students returning from a leave of absence at Cleveland State University. It contains several sections for students to complete depending on their student type and academic status. Section A determines if a student needs to reapply based on attendance at other institutions. Section B checks for academic dismissal requiring a petition. Section C acknowledges the student's catalog rights will update. Section D discloses criminal charges or dismissals. Section E provides residency information. Section F collects contact and signature. The form requires disclosure of academic and legal issues during the leave for consideration of readmission.

Uploaded by

jerrytouille
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Request to Return from

Leave of Absence
Division of Enrollment Services

Student Name: CSUID / SSN (last 4):

 Check box if you are a Graduate student and begin at Section C. Circle the semester in which you are requesting
readmission and indicate the year:
 Check box if you are a Post Baccalaureate student and begin at Section C.

 Check box if you are a Partnership student having only attended CSU or Partnership
college and then begin at Section C. (Otherwise proceed to Section A) Fall Spring Summer Year:____________

 Check box if you are an Undergraduate student, and begin at Section A.

Section A
I have attended another college or university since my last term of enrollment at Cleveland State University. Y* N
*If yes, you must reapply for admission. Reapply online at http://www.csuohio.edu/engagecsu/apply.html. If no, proceed to Section B.

Section B
My most recent term of enrollment at Cleveland State University resulted in an Academic Dismissal, Suspension, or Separation. Y* N
*If yes, you are required to petition for readmission through the academic college you wish to enter. To initiate the petition process,
contact the advising office of the academic college to which you wish to be readmitted. If no, proceed to Section C.

Section C - Catalog Rights Acknowledgement


By initialing this section (required) and submitting this form you acknowledge that your catalog rights will be updated to Initials:
the current term. This change will impact your degree requirements and you are acknowledging that you understand how
this action impacts your academic career. If you are not clear how this action affects your academic career, do not initial __________________
this section and please consult your advisor for further details prior to proceeding.
Proceed to Section D
Section D MUST BE COMPLETED
Have you ever plead guilty or been convicted of a criminal offense or have charges pending against you at this time? Y* N
(at all times as an applicant or a student, you are required to notify the Dean of Students if a plea, conviction, or charges pending occur.)

Have you ever been dismissed, suspended or placed on probation by any other college, university, or high school for a Y* N
NON-ACADEMIC reason?
*If you answer yes to either question, please submit a detailed written explanation of your specific situation to the Office of the University
Registrar with this form. This request will not be considered until the written detailed statement is received.
Proceed to Section E
Section E - Residency Information
Are you a permanent resident of Ohio? (circle one) Y / N *Date Ohio Residency Established (mm/dd/yyyy): Visa Type (if applicable):

*Note: If you have lived in Ohio since birth, please enter birth date for “Date Ohio Residency Established”. Proceed to Section F
Section F - Personal Information
Address: Email Address:

City: State: Zip: County (if US):

Date of Birth (mm/dd/yyyy): Home Telephone #: Work Telephone #:


( ) ( )

I certify that the information herein is complete and accurate to the best of my knowledge. I understand that any misrepresentation or omission is considered
academic dishonesty and is cause for admission revocation and registration cancellation. I further understand that courses completed at another college or university
will not be considered for transfer credit, regardless of circumstances, unless acknowledged during the appropriate readmission process. I agree to abide by all
university regulations as set forth in the applicable Catalog.

*Signature (required): ___________________________________________________ Date: _______________

Requests completed by mail may be returned to:


Office of the University Registrar 2121 Euclid Avenue, Cleveland, Ohio 44115-2214
| Rev. 04/2014
Please return completed form to Campus411All-in-1 in MC 116 or fax to 216-687-5501

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