Form 13768 - Electronic Tax Administration Advisory Committee Membership Application
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1
2Department of the Treasury - Internal Revenue Service
13768
OMB Number
Form
Electronic Tax Administration Advisory Committee
1545-2231
(March 2017)
Membership Application
Monday, April 24, 2017
Complete this application and return it to the address below by
.
You may also fax your application to: 855-811-8020.
Internal Revenue Service National Public Liaison
Attn: ETAAC Program Manager (Room 7559) CL:NPL
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
used
Date
name
were used
(s)
(s)
(s)
Home 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
(Complete the remainder of this section)
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,
experience, and qualifications as they relate to the following:
• Experience in cybersecurity and information security
• Experience in tax software development
• Experience in tax preparation
• Experience in payroll and tax financial product processes
• Experience in systems management and improvement
• Experience in implementation of customer service initiatives
• Experience in consumer advocacy and public administration
• Ability to examine issues from a macro viewpoint, and effectively communicate recommendations
Part IV - 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.
13768
Catalog Number 47884W
Form
(Rev. 3-2017)
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