MA-936 Request for Deferment of Service Obligation

Expiration: 01/31/2018
OMB No. 2133-0510

U.S. Department of Transportation
Maritime Administration

REQUEST FOR DEFERMENT OF SERVICE OBLIGATION

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

2. Social Security No.

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

4. Deferment Dates (Month / Year)
From

5. Name of Maritime School

6. Year of Graduation

To

7. Graduate School Information
Name of Graduate School

(Street, City, State, Zip Code)
Title of Graduate Program (Attach to this form an acknowledgement from the graduate school that.you have been accepted)

Description of Graduate Program

Date

8. Signature of Applicant

PART II. MARITIME ACADEMY PRESIDENT / SUPERINTENDENT RECOMMENDATION

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

Signature (President l Superintendent)

Date

FOR MARITIME ADMINISTRATION USE ONLY
Academies Program Officer, Maritime Administration

Approve

Disapprove

Remarks

Signature (Academies Program Officer)

FORM MA-936 (Rev 5/2008)

Date

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