Information Reporting Program Advisory Committee
OMB Number
1545-1791
Membership Application
PART IV – Applicant Resume
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, include name of the councils/committees and dates of membership.
Councils/Committee name
Dates of Membership
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.
12339-B
Department of the Treasury–Internal Revenue Service
Form
(Rev. 3-2012)
Catalog Number 48518X
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