12339-B Information Reporting Program Advisory Committee Members

OMB No. 1545-1791

Information Reporting Program Advisory Committee
Membership Application
Please complete this application and return it to the following address no later than CLOSE OF BUSINESS on May 30, 2008.
Internal Revenue Service
National Public Liaison
CL: SRM - Room 7559 IR
Attn: Caryl Grant
1111 Constitution Avenue, N.W.
Washington, DC 20224

You may also fax your application to: 202-622-8345

PART I – Applicant Information (Some of the information requested in Part I is required for your FBI background check)
Maiden name or other name(s) used
Date(s) names were used
Name
Home street address

Home telephone number

City
Date of birth (mm-dd-yyyy)

State

ZIP Code

City of birth

State of birth

Business name
Business address

Job title

City
Business telephone number

State

ZIP Code

Business FAX number

E-mail address

PART II – Applicant must complete and return Form 12339-A, Tax Check Waiver, with this form
PART III – Desired Skills and Qualifications
Please submit a short (one or two page) statement, including recent examples, addressing your specific skills and qualifications as they
relate to the following:
Experience working with tax information reporting.
Experience working with an advisory group or committee of a professional organization.
Experience developing and presenting issue resolution and recommendations.
Experience developing and implementing customer service initiatives and tools.
Experience in change management and improvement.
Experience establishing successful strategic partnerships.
Ability to examine issues from a ''macro'' viewpoint, and effectively communicate recommendations.
PART IV – Applicant Resume
Please attach a copy of your resume, including prior Treasury and/or IRS employment. State position(s), title(s), and dates of
employment. In addition, list professional credentials, membership in professional organizations, and local liaison activities with IRS, if
applicable.
PART V – Other IRS Councils/Committees
Have you ever been a member of the Internal Revenue Service Advisory Council (formerly known as CAG), Art Advisory Panel,
Electronic Tax Administration Advisory Committee, Tax Exempt Advisory Committee or Information Reporting Program Advisory
Committee? If so, please include name of the councils/committees and dates of membership.
Councils/Committee name

Form 12339-B (Rev. 3-2008)

Dates of Membership

Catalog Number 48518X

www.irs.gov

Department of the Treasury-Internal Revenue Service

PART VI – Applicant Acknowledgement
I certify that to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith.
Applicant signature
Date signed

PRIVACY ACT STATEMENT
The Privacy Act of 1974 requires that when we ask you for information about yourself, we state our legal right to do so, tell you why we
are asking for it, and how it will be used. We must also tell you what could happen if we do not receive it, and whether your response is
voluntary, required to obtain a benefit, or mandatory. Our legal right to ask for the information is Public Law 92-463 and Executive
Order (E.O.) 9397. We are asking for the information in order to perform Federal income tax, FBI, and practitioner checks as required of
all members and applicants to the Advisory Council/Committee.
Supplying the information is voluntary and not directly required by law, but facilitates the processing of your application for membership
in the IRS Advisory Council/Committee. Requesting your social security number, which is solicited under authority of E.O. 9397, is also
voluntary and no right, benefit, or privilege provided by law will be denied as a result of refusal to disclose it. However, not providing all
or any part of the information may limit consideration of your application.
Form 12339-B (Rev. 3-2008)

Catalog Number 48518X

www.irs.gov

Department of the Treasury-Internal Revenue Service