Free Form 13768 (Rev. 1-2009) - Federal

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Date: January 15, 2009
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State: Federal
Category: Tax Forms
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Electronic Tax Administration Advisory Committee Membership Application
Please complete this application and return it to one of the following addresses by Friday, April 3, 2009

Internal Revenue Service ETA and Refundable Credits ETAAC Analyst (C4-226) SE:W:ETARC:S:RM 5000 Ellin Road (M/S C4-470) Lanham, MD 20706 PART I
Name Home Address City Date of birth (required for FBI check) Business name Business address City Business telephone number State


e-mail Address:

You may also fax your application to: 202.283.2845

Maiden name or other name(s) used and date(s) (required for FBI check) Home telephone number State Zip Code

City and State of Birth (required for FBI check)

Job title ZIP Code E-mail address

Business FAX number

PART II 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: 1. Experience in electronic tax administration including e-commerce, e-gov, and e-filing, payment and communication options. 2. Experience in strategic planning and/or change management. 3. Experience in systems management and improvement. 4. Experience in implementing customer service initiatives. 5. Experience in sales or marketing to individual and small business consumers. 6. Experience in public policy development. 7. Hands-on experience resolving major issues in key market segments. 8. Experience in the development of effective communication networks within the tax community. 9. Experience establishing strategic partnerships with external groups, including Federal and state entities. 10. Ability to formulate, develop, and present proposals for the ETAAC and Commissioner's consideration. PART III Please attach a copy of your resume, to include prior Treasury and/or IRS employment, please state position(s), title(s), and dates of employment. In addition, please list professional credentials, membership in professional organizations, and local liaison activities with IRS, if applicable.

Form 13768 (Rev. 1-2009)

Catalog Number 47884W

Department of the Treasury Internal Revenue Service

PART IV Have you ever been a member of the Electronic Tax Administration Advisory Committee (ETAAC), Internal Revenue Service Advisory Council, (formerly known as CAG), Art Advisory Panel, Tax Exempt Advisory Committee, or Information Reporting Program Advisory Committee. If so, please include dates of membership.

PART V I certify that to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith. Signature Date

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 Electronic Tax Administration Advisory Committee (ETAAC). Supplying the information is voluntary and not directly required by law, but facilitates the processing of your application for membership in the ETAAC. 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 13768 (Rev. 1-2009)

Catalog Number 47884W

Department of the Treasury Internal Revenue Service