UEWM Break Request Request Form
(Leave of Absence Form)

Fields marked (*) are required

Term for break:
  1. Spring Summer Fall
Student's Information
  1. U.S. Citizen Permanent Resident F1 Visa Student
  2. ,
  3. No spaces or brackets e.g. 9999999999 Your mobile number is valid

  4. Please enter a valid email address e.g. swapnil@example.com Your email address is now valid

  5. (If you don't have student ID, please enter: 0)
  6. No Yes


  7. Yes No
    (Note: If found that your fee is still not cleared, the registrar reserves the right to cancel your application)


  8. The occurrence of a medical problem Regular break
Please read and check the agreement


  1. I hereby certify that all information provided by me on this form is accurate and I have read, and I understand the Leave of Absense instruction provided by the UEWM office.