Form MA-935 Request for Waiver of Service Obligation

OMB No. 2133-0510

U.S. Department of Transportation

REQUEST FOR WAIVER OF SERVICE OBLIGATION

Maritime Administration

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:

Maritime Administration
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)

3. Home Address

(Street)

2. Social Security Number

(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. If not, list

other reason(s).)

5. Type of Waiver Requested (Check One)

6. Period of Waiver (Month l Year)

Full
Partial (See Block 6)
7. Name of Maritime School

From

To
7a. Year of Graduation

8. Signature of Applicant (Do Not Print)

PART II.

9. Date

FOR OFFICIAL USE ONLY

Academies Program Officer Decision

Approved

Disapproved

Remarks

Signature of Academies Program Officer

FORM MA-935 (Rev. 5/ 2008)

Date

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