Applicant’s name:
Department / Workplace:
Study branch:
Supervisor:
Start date of study:
Form of study:
Study block completed on:
State doctoral exam passed on:
Expected date of handing in doctoral work:
Requested study interruption valid as of:				to:		
Reason for this request:

Signature of doctoral student:

Supervisor’s statement:

Department Head’s statement:

Branch Board statement: