Form 13768 Form 13768 Electronic Tax Administration Advisory Committee Members

Electronic Tax Administration Advisory Committee
Membership Application
Complete this application and return it to the address below by Thursday,

OMB Number
1545-2231

May 24, 2012.

You may also fax your application to: 202.283.2845.
Internal Revenue Service
Return Preparer Office
ETAAC Analyst (C4-213)
SE:RPO
5000 Ellin Road (M/S C4-470)
Lanham, MD 20706
Federally registered lobbyists cannot be members of the Advisory Committee on Electronic Tax Administration.
Are you a federally registered lobbyist?
No

Yes (You are not eligible to apply. Do not complete this application.)

PART I - Applicant Information (Some of the information requested in Part I is required to perform an FBI background check)
Name
Maiden name/other name(s) used Date(s) name(s) were used
Home Address

Home telephone number

City
Date of birth (mm-dd-yyyy)

State

Zip Code

City of Birth

State of Birth

Business name
Job title

Business address
State

City
Business telephone number

Zip Code
Email address

Business FAX number

PART II - Desired Skills and Qualifications (Complete the remainder of this section)

Submit a short (one or two page) statement, including recent examples, addressing your specific skills and qualifications
as they relate to the following:
1. Experience in electronic tax administration (including e-file, e-pay, etc.);
2. Experience developing security in tax software;
3. Experience in public policy development;
4. Experience implementing customer service initiatives; and
5. Experience in sales or marketing to individual and small business consumers.
Additionally, please include recent examples demonstrating your ability to:
1. Think and plan strategically in order to collaborate on issues and ideas in electronic tax administration;
2. Develop and communicate (oral and written) issues and recommendations;
3. Work cooperatively across industry or business lines to achieve mutually acceptable solutions and recommendations;
4. Interact effectively with a variety of personalities and backgrounds to achieve consensus; and
5. Adopt an IRS-centered mindset separate from personal or business-related perspectives that will benefit all
taxpaying citizens.
PART III - Applicant Resume

Attach a copy of your resume, to include 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.
Form 13768 (Rev. 3-2012)

Catalog Number 47884W

www.irs.gov

Department of the Treasury – Internal Revenue Service

PART IV - Prior IRS Councils/Committees
Have you ever been a member of the Internal Revenue Service Advisory Council, (formerly known as the
Commissioner's Advisory Group), Art Advisory Panel, Electronic Tax Administration Advisory Committee, Tax Exempt
Advisory Committee, Taxpayer Advocacy Panel, or Information Reporting Program Advisory Committee? If so, please
include the name of the councils/committees and dates of membership.
Council/Committee Name

Dates of Membership

PART V - Applicant Signature
I certify that to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in
good faith.
Signature
Date

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 Electronic Tax Administration Advisory Committee (ETAAC).
Supplying the information is voluntary and not directly required by law, but facilitates the processing of your application for membership
in the ETAAC. 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 13768 (Rev. 2-2012)

Catalog Number 47884W

www.irs.gov

Department of the Treasury – Internal Revenue Service