MA-937 Application for Review of Waiver Deferment Decision

OMB No. 2133-0510
Expiration Date: 11/30/2014
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of
information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control
Number for this information collection is 2133-0510. Public reporting for this collection of information is estimated to be approximately 30 minutes per response, including the time
for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Maritime
Administration, MAR-390, 1200 New Jersey Avenue, SE, Washington, DC 20590.

APPLICATION FOR REVIEW OF WAIVER/DEFERMENT DECISION
U.S. Department of Transportation
Maritime Administration

PART I. INSTRUCTIONS: Applicant must complete Part I. 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 request for review.

1. Name (Last, First, Middle)

2. Social Security Number

3. Address (Street, City, State and Zip Code)

4. Is this an appeal of a disapproved waiver or deferment request?
____ Waiver

____ Deferment

5. Reason for Appeal

6. Signature of Applicant

Date

7. Recommendation

____ Approved
____ Disapproved

8. Remarks

9. Signature of Academies Program Officer

PART II.
10. Decision

Date

MARITIME ADMINISTRATOR
____ Approved
____ Disapproved

11. Remarks

Signature of Maritime Administrator
Form MA-937 (Revised 11/2014)

Date