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 address below no later than Close of Business on
You may also fax your application to: 202-622-8345.
Internal Revenue Service
National Public Liaison
CL: NPL – Room 7559 IR
Attn: IRPAC Program Manager
1111 Constitution Avenue, N.W.
Washington, DC 20224

May 31, 2011.

PART I – Applicant Information (Some of the information requested in Part I is required to perform an FBI background check)
Name

Maiden name or other name(s) used

Date(s) names were used

Home street address

Home telephone number

City

State

Date of birth (mm-dd-yyyy)

City of birth

ZIP Code
State of birth

Business name
Business address

Job title

City

State

Business telephone number

Business FAX number

ZIP Code
E-mail address

PART II – Applicant must complete and submit Form 13775, Tax Check Waiver, with this form
PART III – Desired Skills and Qualifications (Federally-registered lobbyists cannot be members of the IRPAC)
Please submit a brief statement addressing your past or current affiliations and dealings with a particular organization or group that you
represent and how such dealings will allow you to know the view's or position of that particular organization or group. In addition, 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 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 Commissioner's Advisory Group),
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. 2-2011)

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. 2-2011)

Catalog Number 48518X

www.irs.gov

Department of the Treasury–Internal Revenue Service