Form MA-937 Application for Review of Waiver Deferment Decision

OMB No. 2133-0510

U.S. Department of Transportation
Maritime Administration

APPLICATION FOR REVIEW OF WAIVER/DEFERMENT DECISION

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
2. Social Security Number

1. Name (Last, First, Middle)

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

Date

6. Signature of Applicant

7. Recommendation

Approved
Disapproved

8. Remarks

9. Signature of Academies Program Officer

PART II.

Date

MARITIME ADMINISTRATOR

10. Decision

Approved
Disapproved

11. Remarks

12. Signature of Maritime Administrator

Form MA-937 (Rev. 5/2008)

Date

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