APPLICATION FORM

0 0 0 1 0 9
Personal ID Number

Position Applied for Master Date Available from:01.01.2020

1. Personal Data
Family Name: Tahirov First Name: Azer Middle Name: Allahverdi
Place of Birth (City and Country):
Date of Birth: 01.04.1963 Qutqashen /Azerbaijan Citizenship: Azerbaijan
Permanent Address Phone (Home): +994 12 562 23 93
Azerbaijan Baku Mammadamin Rasulzade 5 Phone (Business/ Mobile)+994 51 811 01 51
E-mail: [email protected]/mail.ru

2. Maritime Education
Name of school Town Country From To Type of degree or diploma
Baku maritime college Baku Azerbaijan 1992 1996 Navigator

3. Professional Test
English Test Date Name of Test Score

Professional Test Date Score

Name of Test

Professional Interview Date Result

4. Family Details
Civil Status(Single, Married, Separated, Divorced, Widowed) :
Married
Next of Kin (the first emergency contact) Relationship
+994 50 740 32 72 Wife

Address of Residence Phone :

Daughter Son
Family Name Tahirli

Page 1 of 6
WWW.AZ-MARINER.AZ
 First Name Altair
Date of Birth 16.11.2001
City of living Baku
Phone Numbers +994 50 859 01 91

Page 2 of 6
WWW.AZ-MARINER.AZ
5. Identity Documents
Document Country Number Place of Issue Issue Date Expiry Date
Azerbaijan DQK 013462 State maritime administration 18.01.2019 18.01.24
Seaman's Book AZE 018193
Azerbaijan PC AZE Azerbaijan AZE 09.06.2018 08.06.2028
Travel Passport C0 1971621
Azerbaijan AZE N Azerbaijan Qutqashen 01.06.2018 Unlimit
Civil Passport 15163094

6. Valid Visa
Country or Union Type Valid Until
NONE NONE NONE

7. Courses Attended and Certificates Obtained

Dates
Document Number
Issue Expiry
Place
Certificate of Competency 000109/21 23.02.21 23.02.26 Republic of
GMDSS DQ-0270-20 30.12.20 30.12.25 Azerbaijan
GMDSS Endorsement DQ-0270-20 30.12.20 30.12.25 State
Automatic Radar Plotting Aids Simulator
(ARPA)
SQ-0309-20 23.12.20 23.12.25 Maritime
Bridge Team Management SW-0367=20 08.01.2020 15.01.25 Administration
Shiphandling & Maneuvering SV-229-20 17.01.2020 25.01.25
ECDIS Training Course SZ-0301-20 18.12.2019 25.12.24
ISM Code SP-1274-20 29.12.20. 25.12.25
Leadership and teamwork DL-0287-20 28.12.20 09.12.25
Ship Security Officer Training Course SG-0017-19 10.01.19 10.01.24

Proficiency in Survival Craft and Rescue Boats SL-1613-22 16.06.22 16.06.27

Advanced Fire Fighting SJ-0889-22 08.07.22 08.07.27
Hazardous ,Hazordaus and harmfull cargoes Sk 0385-22 29.06.22 29.06.27
Advansed training for Oil Tankercargo
SB 0197-22 01.08.22 01.07.27
operations
Basic Trainings SO-0004-21 07.01.21 07.01.26

Medical First Aid Training and Medical Care SM 0166-23 07.03.23 07.03.28
Medical First Aid Training SN 0854-18 29.03.23 29.03.28
Advanced training for chimical tanker cargo
AS-0032-19 01.03.19 01.03.24
operations(A-v/1-1,pa3.1& pa3.2 )

Page 3 of 6
WWW.AZ-MARINER.AZ
8. Physical Data
Height 180 sm
Weight 105 kg
Colour of Hair Brown
Colour of Eyes Brown
Boilersuit Size 56
Shoes Size 45
9. Medical History Yes No
Have you ever signed off a ship due to medical reasons? x
Did you undergo any medical operation in the past? x
Have you consulted a doctor during the last 12 months for an illness/accident?
Do you have any health or disability problems now? x
If yes, please give full details:

Passed: Valid till:

International Medical Examination 15.04.2023 15,04,2024
Vaccination Against Yellow Fiver 16.11.2011 Unlimit
Vaccination Against Diphtheria NIL NIL

10. References (please give name and address of your current or past employer) Office remarks
Name of Company ASCCOUML Navigation 5 Co Ltd.
Name of person to contact Orxan Mustafayev
Address BAKU
Phone +994 55 999 91 69
Name of Company Palmali
Name of person to contact Mahmud Imansoy
Address ISTANBUL
Phone 905349675774

11. Bank address for allotments

Beneficiary Durna TahirovaAbdulla
Account No. AZ891BAZ33811018405041136202
Name of Bank The international Bank of Republic
Azerbaijan Republic Baku city Z. Bunyadov str 30/12 5A TEL/+99 412 562 99 41
Bank Address +99 412 562 93 37 FAX +994125627824

12. Knowledge and experience Yes No

OCIMF vetting experience: X
ISGOT knowledge: X
13. I hereby declare that the above, including Medical History, is true
Place Date Signature

14. For Office use only

Page 4 of 6
WWW.AZ-MARINER.AZ
 15. Seagoing Experience

Vessel’s From To Total

Name of vessel Flag DWT Eng Type HP Manager or Owner Rank
Type d/m/y d/m/y m/d

Iman Bahram Chem oil 4351

liberia 7139 wart Palmali Master 07.10.2022 19.02.2023 4 mnt
Mammadzadeh tanker
Denizhan Trio Panama Cargo 2370 watrt 3750 Trio shipping Master 23.10.2021 18.05,2022 7 mnt
Arslanbey Panama Cargo 3300 skoda 2x840 Cunda Master 02.05.2021 03.09.2021 5 mnt
Universal 3080
Rhone River Panama 6354 wartsila River.shipping.LTD Master 13.09.2020 16.04 2021 7 mnth
cargo
Berat Panama Cargo 3300 wart 3750 Safir com Master 23.06.2019 29.02.2020 8 mnt
Qafur Mammadov Aze Gen cargo 5449 Wart 2x1250 ASCO Master 08,09,2018 07.04,2019 7 mnt
Urla moldova cargo 3350 skoda 2x840 Troyshipping Master 01.10,2017 04.06,2018 9 mnt
Rasul Rza Aze Gen cargo 5400 catrpller 2x1020 ASCO Master 13.09.2016 25,07,2017 10 mnt
Altus Invictus liberia Dvs 1329 catrpiller 2x2300 MEDS Master 21 09 2016 28.01 .2017 4 mnt
Qaradag Aze universal 3500 6NVDS 48 2-U 2x1740 ASCO Master 04.03.2016 01.08,2016 5 mnth
Urla moldova Cargo 3350 skoda 2x840 Troyshipping Master 03.10.1014 12.12.1015 15 mnt
Atlas Wave Comoros Tug 516 zulser 2x650 Atlas marine Master 15.02.2014 15,07 2014 5 mnt
Hera Avatiu cargo 5700 mitsubishi 3489 Troy shipping Master 23.11.2011 18.07.2012 9 mnth

Total rank sea service: Total type of vessel sea service:

Rank Years Type of vessel Years
Master 2006 OIL TANKER 26
LPG ni
DRY CARGO 7
TANKER ICE

WWW.AZ-MARINER.AZ Page 5 of 6
 OIL /CHEMICAL TANKER 2
FERRY 2
Total 17 Total: 37yrs

WWW.AZ-MARINER.AZ Page 6 of 6