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10. Signature and Date

An investigation of your application will be made. An intentionally false statement or a major omission in completing this application is a violation of 18 U.S.C.

1001, and may also be grounds for denial of your application or for later revocation, disbarment, or suspension of your enrollment to practice before the Internal

Revenue Service.

Under penalties for intentional false statements or major omissions, (18 U.S.C. 1001), I declare that I have examined this application, including accompanying

schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete.

(Applicant’s signature)

(Date)

SCHEDULE A (For use by former Internal Revenue Service employees only)

Instructions:

Complete Schedule A only if your enrollment application is based on former Internal Revenue Service employment. Include only qualifying employment.

Section 10.4(b)(3)(i) of Treasury Department Circular No. 230, provides that enrollment on account of employment in the Internal Revenue Service may be

of unlimited scope or may be limited to permit the presentation of matters only of the particular class or only before the particular unit or division of the

Internal Revenue Service for which the former employment in the Internal Revenue Service has qualified the applicant. It shall be requisite for enrollment on

account of such employment that the applicant shall have had a minimum of 5 years continuous employment in the Internal Revenue Service and during such

time was regularly engaged in applying and interpreting the provisions of the Internal Revenue Code and the regulations thereunder. Application for enrollment on

account of employment in the Internal Revenue Service must be made within 3 years from the date of separation from such employment. Attach a copy of your

position description for the employment under which you are basing eligibility for enrollment. Also, please attach any information regarding formal education,

training, licenses and work experience that would impact on the approval of your application for enrollment to practice before the IRS.

FORMER INTERNAL REVENUE SERVICE EMPLOYMENT INFORMATION

1. Enter your date of separation from employment with the Internal Revenue Service (MM/DD/YY):

Application for enrollment on account of employment in the Internal Revenue Service must be made within 3 years from the date of separation from such

employment. The application for enrollment should not be filed until the individual has separated from employment with the Internal Revenue Service.

State the reason(s) you left Internal Revenue Service Employment:

YES

2. While employed with the Internal Revenue Service, were you ever:

a. Reprimanded?

b. Notified of unsatisfactory performance?

c. Suspended from your job?

d. Reduced in pay or grade?