Form 13768 Electronic Tax Administration Advisory Committee Members

Form

13768

(April 2015)

Department of the Treasury - Internal Revenue Service

Electronic Tax Administration Advisory Committee
Membership Application

Complete this application and return it to the address below by Friday,

OMB Number
1545-2231

May 22, 2015.

You may also fax your application to: 202-317-6238.
Internal Revenue Service
Attn: ETAAC Analyst (Room 7045) SE:OLS:SAS
1111 Constitution Ave, NW
Washington, DC 20224
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

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
Email address

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

An ideal member of ETAAC is tech savvy with knowledge about the digital economy and experience analyzing and
synthesizing data, interacting with a variety of stakeholders and communicating complex information to multiple
audiences. Submit a short (one or two page) statement, including recent examples, addressing your specific skills,
experience, and qualifications as they relate to the following:
1. Filing, preparing, or processing tax or information returns/requests electronically (e.g. e‐file);
2. Managing a multi‐channel customer service environment;
3. Developing web or mobile applications, including experience with human‐centered design, front‐end and back‐end
development;
4. Developing software product lines for businesses (specify small/medium sized businesses or large enterprise)
and/or consumers;
5. Working in digital commerce environment or financial institution, including managing large volume of digital
transactions and improving associated processes;
6. Mitigating cybersecurity risks affecting digital commerce, including, but not limited to identity theft, authentication,
and transmission of sensitive data;
7. Incorporating mobile, cloud computing, digital communication, and/or analytics into product or service design;
8. Thinking critically and planning strategically in order to collaborate on digital issues and ideas, preferably electronic
tax administration;
9. Managing large scale‐business transformation, including digital migration, change management and culture
change;
10. Communicating (oral and written) issues and recommendations;
Can you adopt an IRS‐centered mindset separate from personal or business‐related perspectives that will benefit all
taxpaying citizens?
Yes
Catalog Number 47884W

No
www.irs.gov

Form 13768 (Rev. 4-2015)

Page 2

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.
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 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 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.

Catalog Number 47884W

www.irs.gov

Form 13768 (Rev. 4-2015)