Form 12339 - Internal Revenue Service Advisory Council Membership Application

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OMB No. 1545-1791
Internal Revenue Service Advisory Council
Membership Application
June 17, 2011.
Please complete this application and return it to the address below no later than Close of Business on
You may also fax your application to: 202-927-4123.
Internal Revenue Service
National Public Liaison - IRSAC
CL:NPL — Room 7559-IR
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
E-mail address
PART II – Applicant must complete and submit Form 13775, Tax Check Waiver, with this form
PART III – Desired Skills and Qualifications (Federally-registered lobbyists cannot be members of the IRSAC)
Please 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, please
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 in the resolution of complex tax issues.
● Experience developing and implementing customer service initiatives and tools.
● Experience in business management and improvement.
● Experience working in a multi-cultural/multi-lingual environment.
● Experience establishing successful strategic partnerships.
● Ability to examine issues from a ''macro'' viewpoint, and effectively communicate your views and recommendations regarding issues.
PART IV – Applicant Resume
Please attach a copy of your resume, including prior Treasury and/or IRS employment. State position(s), title(s), and dates of
employment. Additionally, list professional credentials, membership in professional organizations, and local liaison activities with IRS,
if applicable.
PART V – Other IRS Councils/Committees
Have you ever been a member of the Internal Revenue Service Advisory Council (formerly known as Commissioner's Advisory Group),
Art Advisory Panel, Electronic Tax Administration Advisory Committee, Tax Exempt Advisory Committee or Information Reporting
Program Advisory Committee? If so, please include name of the councils/committees and dates of membership.
Councils/Committee name
Dates of Membership
(Rev. 3-2011)
Catalog Number 28320P
Department of the Treasury–Internal Revenue Service


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