OSRHE Regional University Baccalaureate Scholarship (RUBS) Leave of Absence Request

Name *

SSN *

Email *

Home Address *

Telephone Number *

Regional University Attending *

Reason for requesting a leave of absence *

Semester(s) for which you are requesting leave *

Current Cumulative Grade Point Average *

Signature of RUBS Recipient *

Date of Request *

mm/dd/yyyy

Supporting Documentation for Leave of Absence *

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