University of California
                               College of Engineering
             Department of Electrical Engineering and Computer Sciences

       REQUEST FOR ACADEMIC LEAVE OF ABSENCE FOR SEVEN CALENDAR DAYS OR LESS


            This form should be submitted to the Department Chairman at
            least one week in advance of the proposed leave.  For
            purposes of verification, faculty members that you designate
            to be in charge of your of classes/advising during your
            absence must initial this form prior to submission for
            approval.


       _____________________________________________   _________________________
                        Name                                  Date

       Absent
       from: ____________________________  to: _________________________________

       Purpose of leave, name of conference, place, title of paper etc.:





       Should this information be publicized in Engineering

       News?           Yes: _________  No: _________

       Where you can be
       reached   Address: _____________________________________________________
       in an emergency:
                          _____________________________________________________

                           Phone
                           Number: ____________________________________________

       Local
       contact            Name: _______________________________________________
      in an emergency:
                           Address: ___________________________________________

                                    ___________________________________________

                           Phone
                           Number: ____________________________________________

       Disposition of classes:      Course

       Number(s): _____________________________________________________________


                           Name(s) of faculty member(s) in


                           charge: ____________________________________________


                           Signature of faculty member in


                           charge: ____________________________________________

       Disposition of
       advising:     Graduate: _________   Undergraduate: _________


                           Name(s) of faculty member(s) in

                           charge: _____________________________________________

                           Signature of faculty member in


                           charge: _____________________________________________


                                     ___________________________________________
                                             Department Chairman


                                     ___________________________________________
                                             Date
       8/89