Form 12339-C - Advisory Committee On Tax Exempt And Government Entities - Membership Application

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Department of the Treasury - Internal Revenue Service
12339-C
Advisory Committee on Tax Exempt and Government
OMB Number
Form
1545-1791
(September 2012)
Entities - Membership Application
.
November 2, 2012
Complete this application and return it to the address below no later than Close of Business on
Internal Revenue Service
Tax Exempt and Government Entities
SE:T:CL/NCA 679
Attn: Roberta B. Zarin
1111 Constitution Avenue, NW
Washington DC 20224
You may also FAX your application to: 202-283-9848.
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
Which Tax Exempt and Government Entities customer segment vacancy are you applying for?
Employee Plans
Exempt Organizations
Federally registered lobbyists cannot be members of the Advisory Committee on Tax Exempt and Government Entities.
Are you a federally registered lobbyist?
Yes
No
PART II – Applicant must complete and submit Form 13775, Tax Check Waiver, with this form
PART III – Desired Skills and Qualifications
Submit a short (one or two page) statement, including recent examples, addressing your specific skills and qualifications as they relate
to the following:
● Applying tax law knowledge related to employee plans, exempt organizations, government entities, or tax exempt bonds.
● Experience in business management and improvement.
● Experience establishing successful strategic partnerships.
● Ability to examine issues from a "macro" viewpoint, and effectively communicate.
● Your views and recommendations about these issues.
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.
12339-C
Form
(Rev. 9-2012)
Catalog Number 58763Y

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