Form MA-936 Request for Deferment 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.

REQUEST FOR DEFERMENT OF SERVICE OBLIGATION

U.S. Department of Transportation
Maritime Administration

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 Number

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

4. Deferment Dates (Month / Year)

5. Name of Maritime School

6. Year of Graduation

From ________________ 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

8. Signature of Applicant

Date

Part II. MARITIME ACADEMY PRESIDENT/SUPERINTENDENT RECOMMENDATION

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

Signature (President/Superintendent)

Date

FOR MARITIME ADMINISTRATION USE ONLY

Academies Program Officer, Maritime Administration
___ Approve

___ Disapprove

Remarks

Signature (Academies Program Officer)
Form MA-936 (Revised 11/2014)

Date