Information Reporting Program Advisory Committee
OMB Number
1545-1791
Membership Application
May 31, 2012.
Complete this application and return it to the address below no later than Close of Business on
You may also FAX your application to: 202-622-8345.
Internal Revenue Service
National Public Liaison
CL: NPL – Room 7559 IR
Attn: IRPAC Program Manager
1111 Constitution Avenue, N.W.
Washington, DC 20224
Federally registered lobbyists cannot be members of the Information Reporting Program Advisory Committee.
Are you a federally registered lobbyist?
Yes (You are not eligible to apply. Do not complete this application)
No (Complete the remainder of this application)
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
Department of the Treasury–Internal Revenue Service
Form
(Rev. 3-2012)
Catalog Number 48518X
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