Form MA-935 Request for Waiver of Service Obligation

U.S. Department ot Transportation

1

Maritime Administration

I

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REQUEST FOR WAIVER OF SERVICE OBLIGATION

PART I INSTRUCTIONS The applicant must complete Part I A waiver may be requested for all or a portion of the service obligation
The completed form should be forwarded to:

p,,qa,jtjme,qdministration
Academies Program Officer
1200 New Jersey Avenue, SE
Washington, DC 20590

The Maritime Administration will notify the applicant of the decision made on the waiver request.

1. Name (Last, First, Middle)

2. Social Security Number

3 Home Address (Street)

(City, State, Zip Code)

4. Reason for Waiver Request (If a medical condition precludes you from honoring your service obligation, attach a verifying letter from your physician. I f not, list

other reason(s).)

5 . Type of Waiver Requested (Check One)

6. Period of Waiver (MonthlYear)

Full
Partial (See Block 6)

From

To

7. Name of Maritime School

7a. Year of Graduation

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8. Signature of Applicant (DONot Print)

PART II.

9. Date

FOR OFFICIAL USE ONLY

4cademies Program Officer Decision

Approved

iignature of Academies Program Officer

= o m MA-935 (Rev. 512008)

Disapproved

Date