PHYSICS GRAD STUDENT ABSENCE REQUEST

NAME: _________________________________________ DATE: _________________

DATE AND TIME LEAVING: ________________________________________________

DATE AND TIME RETURNING: ______________________________________________
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UNIVERSITY BUSINESS ________         PERSONAL BUSINESS ________

PURPOSE OF TRIP (if business related) __________________________________________

__________________________________________________________________________

SOURCE OF FUNDS/ACCOUNT NUMBER (if business related) ______________________

ADDRESS WHERE YOU CAN BE REACHED

_________________________________________________________________________

_________________________________________________________________________

Phone: _________________________________ Email: _____________________________

TEACHING RESPONSIBILITY DELEGATED TO:

CLASS, DAY/TIME	TEMPORARY REPLACEMENT	SIGNATURE

If you have more classes than number of lines please attach separate sheet!

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^{for office use only}

This request is (circle one):	APPROVED	DISAPPROVED
Support during this period:	Continue Full	Pro-Rate for time gone	None

_________________________________            _________________________________
Signature Academic/Research Advisor                    Signature Department Chair