Form 12339-B - Information Reporting Program Advisory Committee Membership Application

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Department of the Treasury - Internal Revenue Service
OMB Number
Information Reporting Program Advisory Committee
(January 2015)
Membership Application
May 29, 2015.
Complete this application and return it to the address below no later than Close of Business on
You may also FAX your application to: 855-811-8020.
Internal Revenue Service
National Public Liaison
CL: NPL – Room 7559 IR
Attn: IRPAC Program Manager
1111 Constitution Avenue, N.W.
Washington, DC 20224
PART I – Applicant Information (Some of the information requested in Part I is required to perform an FBI background check)
Maiden name or other name
names were used
Home street address
Home telephone number
ZIP Code
Date of birth
City of birth
State of birth
Business name
Business address
Job title
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
● 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.
Catalog Number 48518X
(Rev. 1-2015)


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