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

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Department of the Treasury - Internal Revenue Service
OMB Number
Advisory Committee on Tax Exempt and
(Rev. August 2015)
Government Entities - Membership Application
Complete all five parts of this application and return it no later than Close of Business on Friday, September 4, 2015.
NOTE: Incomplete applications will not be processed.
To expedite service, you have the option to mail your form electronically to
You may also FAX your application to (888) 269-7419 (secure).
If you require alternative means to send the form, please call (202) 317-8798.
PART I – Applicant Information
(Some of the information requested in Part I is required to perform an FBI background check)
First name
Middle name
Last name
Home street address
Telephone number
ZIP Code
Business name
Job title
Business address
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
Federal, State and Local Governments
Indian Tribal Governments
PART II - Desired Skills and Qualifications
Attach 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 III - 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.
(Rev. 8-2015)
Catalog Number 58763Y


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