Form 13768 - Electronic Tax Administration Advisory Committee Membership Application
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1
2Electronic Tax Administration Advisory Committee
OMB Number
1545-2231
Membership Application
Thursday, May 24, 2012
Complete this application and return it to the address below by
.
You may also fax your application to: 202.283.2845.
Internal Revenue Service
Return Preparer Office
ETAAC Analyst (C4-213)
SE:RPO
5000 Ellin Road (M/S C4-470)
Lanham, MD 20706
Federally registered lobbyists cannot be members of the Advisory Committee on Electronic Tax Administration.
Are you a federally registered lobbyist?
No
Yes (You are not eligible to apply. Do not complete 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/other name(s) used
Date(s) name(s) were used
Home Address
Home telephone number
City
State
Zip Code
City of Birth
Date of birth (mm-dd-yyyy)
State of Birth
Business name
Job title
Business address
State
City
Zip Code
Business telephone number
Email address
Business FAX number
PART II - Desired Skills and Qualifications (Complete the remainder of this section)
Submit a short (one or two page) statement, including recent examples, addressing your specific skills and qualifications
as they relate to the following:
1. Experience in electronic tax administration (including e-file, e-pay, etc.);
2. Experience developing security in tax software;
3. Experience in public policy development;
4. Experience implementing customer service initiatives; and
5. Experience in sales or marketing to individual and small business consumers.
Additionally, please include recent examples demonstrating your ability to:
1. Think and plan strategically in order to collaborate on issues and ideas in electronic tax administration;
2. Develop and communicate (oral and written) issues and recommendations;
3. Work cooperatively across industry or business lines to achieve mutually acceptable solutions and recommendations;
4. Interact effectively with a variety of personalities and backgrounds to achieve consensus; and
5. Adopt an IRS-centered mindset separate from personal or business-related perspectives that will benefit all
taxpaying citizens.
PART III - Applicant Resume
Attach a copy of your resume, to include 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.
13768
Form
(Rev. 3-2012)
Catalog Number 47884W
Department of the Treasury – Internal Revenue Service
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