Form MA-935 Request for Waiver of Service Obligation

OMB No. 2133-0510
Expiration Date: 09/30/2021
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 10 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.

U.S. Department of Transportation
Maritime Administration

REQUEST FOR WAIVER OF SERVICE OBLIGATION

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/Year)

___ Full
___ Partial (See Block 6)

From __________________________ To __________________________

7. Name of Maritime School

7a. Year of Graduation

8. Signature of Applicant (Do Not Print)

9. Date

Part II.

FOR OFFICIAL USE ONLY

Academies Program Officer Decision
___ Approved
Remarks

Signature of Academies Program Officer

Form MA-935 (Revised 11/2014)

Date

___ Disapproved