TERM STOP-OUT REQUEST FORM

Student Name: DAI, YANG YI SSN: 666-67-0877

Program: OFFICE TECHNOLOGY AND ID No. 191018-377

ADMINISTRATION (CERT)
Start Date: 10/08/2019

Reason for request: X

Student phone # : ____________________________ Student personal e-mail:__________________

Student Address: _____________________________________________________________________________________

Effective Dates: from 06/11/2020 to 09/23/2020

mm/dd/yy mm/dd/yy

DISCLOSURE STATEMENT
In requesting for a leave of absence, I hereby acknowledge that I understand and accept the following stipulations:
 That I have completed all course requirements of my current semester and fulfilled the satisfactory academic progress (SAP) requirements of ASA as well.
 That this leave of absence is for a period of one semester within a calendar year.
 That I am expected to return to active student status at the end of my LOA, which is indicated above.
 That my failure to return to student status from my approved leave of absence on the date indicated above will merit my official dismissal from ASA.

Signature of Student: X______________

_
A. Student Advisement Office (R320):________________________________________________________________________________
____________________________________________________________________________________________
Date
Full name Signature

Student has been advised by the Financial Aid Office that financial aid eligibility may be affected, and TAP eligibility may be reduced as a
result of an approved leave of absence.
B. Financial Aid Office(1st FL):
Date
Full name Signature
Student Account Office (R203)

Full Name Signatire Date

C.
International Student Advisor / Athletic Department (if and when applicable):
Date
Full name Signature

D. Registrar’s Office(R202): Cum GPA 0 LDA 06/01/2020

NOT VALID UNLESS RETURNED TO REGISTRAR’S OFFICE

 Svetlana
Gorovets Date 6/4/2020
Full name Signature