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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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File Type | application/pdf |
File Modified | 2015-01-29 |
File Created | 2008-05-27 |