1. WPIF – M/01 12TH
July 2011 Rev - 02
Application Form Deck & Engineering Officers
Section 1 Position
Position Applied for Master
Lowest Position Acceptable --------------
Date of Availability July / 06 / 2016
Section 2 Personal Details
Family name / Surname Taghiyev
First Name / Given Name Jankishi Aziz
Date & Place of Birth Date – 26/12/ 1959 Place- Masalli /Azerbaijan
Nationality Azeri
Permanent Address Baku, I.Ismailov street, Home 15, Apart. 50
Present Address Baku, I.Ismailov street ,Home 15, Apart.50
PPE information SAFETY SHOES SIZE 41 COVERALL SIZE LM
Present Contact Number Home: +994 12 371 58 46
Mobile Number Mob : +994 50 204 09 55
SKYPE ADDRESS Jan.tagiyev
Email Address jan.59@mail.ru
Nearest Airport (and Distance) Baku, 30 km.
Section 3 Passport and VISA details
Country of Issue AZE USA Visa - Type B1/OCS
Date Issued 01/07.2008 USA VISA Expires
Place Issued AZE USA Visa - Type C1/D
Passport Number P 3346710 USA VISA Expires
Passport –Expires 01/07/2018 Other Country Visa N/A
Secondary passport or Dual nationality Visa Expiry N/A
Section 4 ( hi-light as required ) Seaman book / Discharge book / Seaman Record Book / CDC
Issuing Country & Place AZE, Sea port Date Issued 21/02/2013
Number DQK 008103 Expiry Date (if any) 21/02/2018
Section 5 Next of Kin – this is important information we require- Don’t ignore it
Full Name / Relationship Wife : Shalala
Any dependents / Children (incl age ) Sons : Rustam -22 , Kamran -18
Address I.Ismailov street, Home 15,Apart.50
Contact Numbers + 994 12 371 58 46
Page 1 of 7
Section 6 STCW95 Highest Certificate of Competency / Licence Held ( also list Flag State Endorsements)
Class /
Grade/Capacity
Issuing Country Certificate No. Date Issued Expiry Details of Limitations
II/2;IV/2 AZE 000317/16 16/05/2016 15/05/2021 Unlimited/3000 GRT
& more
Marshall isl. 2012 2016
Qatar, S.Vinc 2013 2018
ALSO ENTER ABOVE DETAILS OF ANY OTHER FLAG STATE CERTIFICATES HELD
2. WPIF – M/01 12TH
July 2011 Rev - 02
Section 8 STCW95 related Courses Attended and Certificates Obtained
Name of Course / Certificate STCW Code Place Issue Date Cert No Expiry Date
Personal Survival Techniques A-VI/1-1 AZE 30/12/2011 2-03229/11 30/12/2016
Basic Sea Survival / Training
Fire Prevention & Fire Fighting A-VI/1-2 AZE 30/12/2011 2-03229/11 30/12/2016
Elementary First Aid A-VI/1-3 30/12/2011 2-03229/11 30/12/2016
Personal Safety & Social Responsibility A-VI/ 1-4 AZE 30/12/2011 2-03229/11 30/12/2016
Dangerous,hazardous and harmfull
cargoes(IMO Model Course 1.10)
B-V/b,B-
V/c
AZE 19/12/2011 00794/11 19/12/2016
Proficiency in Survival Craft & Rescue
Boats
A-VI/ 2-1 AZE 27/12/2011 3-01641/11 24/12/2016
Proficiency in RESCUE CRAFTS UAE 09/03/2012 NU/HSE/1529 09/03/2017
Advanced Fire Fighting A-VI/ 3 AZE 04/02/2013 SJ-0107-13 04/02/2018
Medical & First Aid A-VI/ 1-3 AZE 30/12/2011 2-03229/11 15/12/2016
Medical Care
( Ship Captains Medical Course )
A-VI/4-2 AZE 27/12/2011 MC 0731/11 27/12/2016
Radar & ARPA Simulator Trg-
Management level
A-II/ 1-2 AZE 04/06/2012 SQ-0148-12 04/06/2017
GMDSS + ENDORSEMENT A-IV/ 2 AZE 06/06/2012 DQ-0180-12 06/062017
SAFETY OFFICERS COURSE (SO)
Ship Security Officers Course (SSO)
Issued under STCW95
A-VI/ 5 AZE 06/05/2016 SG-0077-16 06/05/2021
Medical Certificate / HEALTH
Certificate
AZE 16/05/2016 1439 16/05/2017
Drug and Alcohol test certificate
YELLOW FEVER MediClub 21/06/2012 PE 01 CU 10 years
Bridge Team Management A-II/2 AZE 10/05/2016 SV-0130-16 10/05/2021
Bridge Resources Management B-VIII/2 AZE 29/04/2016 SW-0165-16 29/04/2021
Electronic chart Display and
Information System course ( ECDIS )
A-II/I,A-
II/2
AZE 16/05/2016 SZ-0121-16 16/05/2021
ISM Code A.1441 (18) AZE 29/12/2011 1-01706/11 27/12/2016
TANKERS FAMILIARISATION
Advanced Tanker Operations (Chem.) A-V/1-2
Advanced Tanker Operations (Oil)
INERT GAS (H2S) OTI 22/10/2015 052901422101
500488
21/10/2017
CRUDE OIL WASHING
Tanker Safety ( petroleum )
Tanker Safety ( Chemical )
Tanker Safety ( GAS )
REFRESHER & UPDATING I/II & III/2 AZE 10/05/2016 XS-0158-16 10/05/2021
FIRST RESCUE GRAFT TRAINING 09/03/2012 NU/HSE/1529
Other ????
Other ????
Page 2 of 7
Section 9 OFFSHORE INDUSTRY COURSES
Please enter below any other certificates held or courses done, ie offshore, DP certs etc or Any other not already mentioned
Name of Course / Certificate APPROVALS Place Issue Date Cert No Expiry
BOSIET ABC’S of H2S and SCBA Maersk (MOQ ) OTI- AZE 22/10/2015 0529014
2210150
0488
21/10/201
7
HUET GTSC UAE-
AbuDhabi
10/08/2014 09/08/201
6
FOET
OFFSHORE MEDICALS
( UK, NORWAY or NETHERLAND )
L
I
S
T
A
L
L
O
T
H
E
R
3. WPIF – M/01 12TH
July 2011 Rev - 02
Re-Breather training
Initial Standby vessel crews training ( ITSO )
CAA (Civil Aviation Authorities –
Helicopter)
Advanced Medical Aider ( AMA )
HLO
MARLIN’s English Test Score: N/A
IELTS-English TEST http://www.ielts.org/test_centre_search/search_results.aspx SCORE
DEEP WATER ANCHOR HANDLING EXPERIENCE ENTER DEPTTH IN METERS 81 mtrs
DP Maintenance Courses
DP Maintenance Courses
HIGH VOLTAGE COURSE
Dynamic Positioning Induction Course St.Petersbourg Russia 01/10/2010 IDP 644/10
Dynamic Positioning Simulator Course St.Petersbourg Russia 16/12/2011 SDP 480/11
Dynamic Positioning Operators
CERTIFICATE
Full or
Limited
Dynamic Positioning Log book Details On DP-1 16 months
Section 10 Hours done with various DP system
SYSTEM DETAILS Approx Hours as SDPO / Approx Days
in case of Senior ETO / Senior Engineer
Approx Hours as DPO / Approx Days in
case of Junior ETO / Junior Engineer
Kongsberg OS-11 S Fambeem, tout wire, reflector, More than 280 hours
DGPS
APPROXIMATE Total DP Hours in Various Operations
SAT DIVING CABLE LAYING
AIR DIVING SURVEY
ROV PIPE LAYING
WELL STIMULATION / INTERVENTION /
ACTIVATION
DRILL SHIP / SEMI SUB
AHTS 9 month PSV 11 months
FPSO SHUTTLE TANKER
CONSTRUCTION ROCK DUMPING / MATTRESSING
CORING TRENCHING
HEAVY LIFT ACCOMMODATION / GANGWAY
Page 3 of 7
Section 11 Medical History
YES NO
Have you ever signed off a ship due medical reason ? NO
Have you undergone any medical operations in past? NO
Have you consulted a doctor during the past 12 months for an illness / Accident NO
Do you have any health or disability problem now?? NO
4. WPIF – M/01 12TH
July 2011 Rev - 02
If answer to any of above is YES then give further details below or on a separate sheet
NOTE : All our clients have STRICT Alcohol and Drug Policy, Which
means ZERO TOLERENCE for alcohol and drugs
Section 12 General
Yes No
Have you ever been the subject of a court of enquiry or involved in a maritime accident NO
Have you ever had a professional licence suspended or revoked NO
Have you ever been convicted of any criminal offence? NO
Have you ever been dismissed NO
If yes to any of above then please full details below or on separate sheet of paper
Section 13 References (Last Two Recent Employers)
Name of company HOSC (Halul offshore services comp.) Qatar
Name Person to be contacted DPA Mohit ,Crew manager Donnalisha, Capt.Robert Lee
Address Doha,Al Fardan building 3 rd Floor
Tel No +974 4339111 Fax +974 4318647 , 441 0338
Email General : hosc@haluloffshore.com , mohit@haluloffshore.com
Name of company Topaz Marine MENA
Name Person to be contacted Shyam Kumar – marine coordinator,
Address P.O.Box 37102, Doha- State of Qatar
Tel No +974 44104800 Fax +974 44479473
Email shyam.kumar@topaz-marine.com ,
Section 14 Any other information, you wish to add in support of your application
On Middle East : Last 3 years worked on Atlantic Maritime Group vessels. On DP charter DNO
Pentagon, Saudi Aramco-Supply,Ahts,Rig move & AH with PL barge Hyundai 423 on the pipe line 84
KM,Rasslafan-Alshahin(Qatar).
Company person E-mail: eva@amguae.net Crew Department,
mariano@amguae.net DPA, Port Captain.
Section 15 Declaration
I hereby declare that the above particulars are true and I authorize you to contact the referees listed above
And confirm that All my certificates / Licences are Authentic / SEASERVICE RECORD is ACCURATE / And I
confirm accepting Companies DRUG & ALCOHOL Policy
Signed …J . TAGHIYEV………………………
Date…06. 07. 2016………………..
Page 4 of 7
5. WPIF – M/01 12TH
July 2011 Rev - 02
Section 16 Record of Sea Service (last 10 years) (All Dates to be entered as dd/mm/yy
Please give full record of sea service STARTING FROM LAST VESSEL FIRST
VESSEL COMPANY Type of Vessel
And Type of operation in
case of DP vessels
DWT or GRT
(please delete as reqd)
Type of Engines
Or DP System
BHP RANK Sign on
DATE
Sign off
DATE
add / mm / yy dd / mm / yy
M/V Sumgayit Casp.Shipping
Company/AZE
PSV 1969 Rols Roys 2x2725 Master 20.04.16 22.06.16
M/V Sumgayit Casp.Shipping
Company/AZE
PSV 1969 Rols Roys 2x2725 Master 10.01.16 21.03.16
M/V Sumgayit Casp.Shipping
Company/AZE
PSV 1969 Rols Roys 2x2725 Master 19.09.15 23.11.15
M/V Castle Casp.Shipping
Company/AZE
PSV 1969 Rols Roys 2x2725 Master 05.05.15 02.07.15
M/V Castle Casp.Shipping
Company/AZE
PSV 1969 Rolls Roys 2x2725 Master 22.01.15 30.03.15
AOS
Hauler(DP-1)
AMG/UAE AHTS/ AH 1537 Caterpillar 2x2575 Master 07.08.14 09.12.14
AOS
Hauler(DP-1)
AMG/UAE AHTS/PSV 1537 Caterpillar
Kongsberg OS-1
2x2575 Master 12.02.14 08.04.14
AOS
Hauler(DP-1)
Atlantic Maritime
Group/UAE
AHTS/PSV 1537 Caterpillar
Kongsberg OS-1
2x2575 Master 24.10.13 12.02.14
AOS
Hauler(DP-1)
Atlantic Maritime
Group/UAE
AHTS/PSV 1537 Caterpillar
Kongsberg OS-1
2x2575 Master 05.03.13 28.06.13
AOS
Hauler(DP-1)
Atlantic Maritime
Group / UAE
AHTS/ PSV 1537 Caterpillar
Kongsberg OS-1
2x2575 Master 06.12.12 24.12.12
AOS
Provider(DP-1)
Atlantic Maritime
Group / UAE
AHTS/ PSV 1537 Caterpillar
Kongsberg OS-1
2x2575 Master 06.08.12 05.12.12
Topaz Khobar
(DP-1)
Topaz Marine
MENA / Qatar
AHT/AH(KSA) 1678 Caterpillar
Kongsberg OS-1
2x2575 Master 30.01.12 07.04.12
Topaz Khobar
(DP-1)
Topaz Marine
MENA / Qatar
AHTS/AH & Rig
move
1678 Caterpillar /
Kongsberg OS-1
2x2575 Master 01.10.11 30.11.11
SAEB (DP-1) UAE /WSS AHTS/PSV& Rig
move
1579 Wartsila / Kongs
OS-11 S
2x 2750 Master 09.11.10 12.05.11
HALUL-26
(DP-1)
QATAR-HOSC AHTS/PSV 1991 --------------
Kongsberg OS-1
2x 2750 Master 23.01.10 25.04.10
HALUL-28 QATAR-HOSC AHTS/ 1462 caterpillar 2x 2575 Master 28.09.09 06.12.09
HALUL-28 QATAR-HOSC AHTS 1462 caterpillar 2x 2575 Master 23.05.09 28.08.09
7. WPIF – M/01 12TH
July 2011 Rev - 02
ADDITIONAL INFORMATION SHEET
VESSEL TYPE YOU ARE INTERESTED IN (please list in order of priority)
1.TSV
2.AHT
3.AHTSV
4.PSV
5.DP-1 Have experience more than 12 months
MAXIMUM ACCEPTABLE CONTRACT PERIOD (Please indicate below)
3 months
Please Quote –Consolidated MINIMUM MONTHLY SALARY ( no leave pay ) payable for
time onboard only or Working DAY RATE EXPECTATION ( no leave pay)
( please quote below in US$ -preferred or Euro or GBP£ )
USD $ = per/day
Languages Spoken / Written / Understood (1-poor 5-Fluent)
Spoken Written Understood
ENGLISH Good Good Exellent
RUSSIAN Good Good Excellent
TURKISH Good Good Excellent
DRUG & ALCOHOL POLICY
ALL Our Clients have very strict NO DRUG and ALCOHOL POLICY, Which is required to be
complied with at all times, which means “””ZERO TOLERENCE on ALCOHOL & DRUG”””
Your body must NOT have any ALCOHOL or DRUG substances from the time you board your flight
or commence your travel to join vessel, and Must remain so Until you have completed full contract
and returned to your home Airport / Town
If during the said period you are found under the influence of DRUG or ALCOHOL then ALL
EXPENCES incurred which will include all your travel and recruiting costs, And your relief’s
Travel and recruiting costs, And Any other costs whatsoever incurred due to your NON-
COMPLIANCE will be deducted from your salary, Which will include but not limited to “damage to
vessel her equipments and machineries, loss of charter, and any other costs Directly or indirectly
connected with your NON-COMPLIANCE
Sign & CONFIRM ACCEPTANCE OF ABOVE POLICY……………………………………
