Fill and Sign the Instructions for Nontaxable Transaction Certificates Form

OMB No. 1545-1791 Internal Revenue Service Advisory Council Membership Application Please complete this application and return it to the following address no later than CLOSE OF BUSINESS on June 15, 2007. Internal Revenue Service National Public Liaison CL:NPL - Room 7559 IR Attn: Jacqueline Tilghman 1111 Constitution Avenue, N.W. Washington, DC 20224 You may also fax your application to: 202-927-5253 PART I – Applicant Information (Some of the information requested in Part I is required for your FBI background check) Maiden name or other name(s) used Date(s) names were used Name Home street address Home telephone number City Date of birth (mm-dd-yyyy) State City of birth ZIP Code State of birth Business name Business address Job title City Business telephone number State Business FAX number ZIP Code E-mail address PART II – Applicant must complete and return Form 12339-A, Tax Check Waiver, with this form PART III – Desired Skills and Qualifications 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 effective communicate your views and recommendations about these 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. In addition, 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 CAG), 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 Form 12339 (Rev. 4-2007) Dates of Membership Catalog Number 28320P www.irs.gov Department of the Treasury-Internal Revenue Service PART VI – Applicant Acknowledgement I certify that to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith. Applicant signature Date signed PRIVACY ACT STATEMENT The Privacy Act of 1974 requires that when we ask you for information about yourself, we state our legal right to do so, tell you why we are asking for it, and how it will be used. We must also tell you what could happen if we do not receive it, and whether your response is voluntary, required to obtain a benefit, or mandatory. Our legal right to ask for the information is Public Law 92-463 and Executive Order (E.O.) 9397. We are asking for the information in order to perform Federal income tax, FBI, and practitioner checks as required of all members and applicants to the IRS Advisory Council. Supplying the information is voluntary and not directly required by law, but facilitates the processing of your application for membership in the IRS Advisory Council. Requesting your social security number, which is solicited under authority of E.O. 9397, is also voluntary and no right, benefit, or privilege provided by law will be denied as a result of refusal to disclose it. However, not providing all or any part of the information may limit consideration of your application. Form 12339 (Rev. 4-2007) Catalog Number 28320P www.irs.gov Department of the Treasury-Internal Revenue Service