Form 12339-B - Information Reporting Program Advisory Committee Membership Application
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1
2Department of the Treasury - Internal Revenue Service
12339-B
OMB Number
Form
Information Reporting Program Advisory Committee
1545-1791
(April 2017)
Membership Application
May 21, 2017.
Complete this application and return it to the address below no later than
on
Close of Business
You may also e-mail your application to: PublicLiaison@irs.gov
Internal Revenue Service
National Public Liaison
CL: NPL – Room 7559 IR
Attn: IRPAC Program Manager
1111 Constitution Avenue, N.W.
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 or other name
used
Date
names were used
(s)
(s)
Home street address
Home telephone number
City
State
ZIP Code
Date of birth
City of birth
State of birth
(mm-dd-yyyy)
Business name
Business address
Job title
City
State
ZIP Code
Business telephone number
Business FAX number
Email address
PART II – Applicant must complete and submit Form 13775, Tax Check Waiver, with this form
PART III – Desired Skills and Qualifications
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, 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.
12339-B
Catalog Number 48518X
Form
(Rev. 4-2017)
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