MA-936 Request for Deferment of Service Obligation

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U.S. Department of Transportation
Maritime Administration

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REQUEST FOR DEFERMENT OF SERVICE OBLIGATION

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PART I. INSTRUCTIONS: The applicant must complete Part I. The form must then be submitted to the President1 Superintendent of the
maritime school from which the applicant graduated, for completion of Part If, before forwarding to the Maritime Administration. The
Maritime Administration will notify the applicant of the decision made on the deferment request.
I. Name (Last, First, Middle)

2. Social Security No.
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3. Home Address (Street, City, State, Zip Code)

4. Deferment Dates (Month near)

From

To

5. Name of Maritime School

6. Year of Graduation

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7. Graduate School Information
Name of Graduate School
School Address (Street, City, State, Zip Code)
Title of Graduate Program (Attach to this form an acknowledgement from the graduate school to which you have been accepted)

Date

8. Signature of Applicant

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PART 11. MARITIME ACADEMY PRESIDENTISUPERINTENDENTRECOMMENDATION

I find
do not find
the applicant meets the standards of superior academic and superior discipline warranting grant of deferment
for further study as prescribed in 46 CFR 310.7(b)(9) and 46 CFR 310.58(g).
Remarks

Signature (Presidentlsuperintendent)

Date

FOR MARITIME ADMINISTRATION USE ONLY
Academies Program Officer, Maritime Administration

Approve

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Disapprove

Remarks

Signature (Academies Program Officer)

Form MA-936 (Rev. 512008)

Date