Survey Questionnaire

OMB Number 1545-1922

The data requested on this form will be used for statistical analysis to evaluate our recruiting program. Submission of this information is voluntary. Please read and complete each question. Circle One Male Female Age Location applying Date List positions applying for: a a

How did you learn about this position? Please circle only one: 1 Newspaper — Which one? _________________________ 2 Radio — What station? ____________________________ 3 TV — What station? ______________________________ 4 State Employment Office (TEC) 5 Agency Personnel Office (IRS) 6 Friend or Relative working for IRS 7 Friend or relative NOT working for IRS 8 Internet ______________________________________ (list web site, ex: USAJobs.opm.gov) 9 Billboard/Marquee 10 Val-Pac 11 Other

The categories below are designed to identify your basic race and national origin. If you are of mixed racial and/or national origin, identify yourself by the category with which you most closely identify yourself. Circle ONLY ONE code next to the appropriate category. Name of Category Code C Black, not of Hispanic origin Definition of Category A person having origins in any of the black racial groups of Africa. Does not include persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish cultures or origins (see Hispanic). A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish cultures or origins. Does not include persons of Portuguese culture or origin. A person having origins in any of the original peoples of the Far Island East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes China, India, Japan, Korea, the Philippine Islands, and Samoa. A person having origins in any of the original peoples of North America, and who maintains cultural identification through community recognition or tribal affiliation. A person having origins in any of the original peoples of Europe, North America, or the Middle East. Does not include persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish cultures or origins (see Hispanic). Also includes persons not included in other categories.

D

Hispanic

B

Asian or Pacific Islander

A

American Indian or Alaskan Native

E

White, not of Hispanic origin

Privacy Act and Paperwork Reduction Act Notices- The information requested on this form will be used to update personnel records. Your name and/or social security number is only used as an identifier (authorized under Executive Order 9397, dated November 1943.) Your response is voluntary. We ask for the information on this form to carry out the mission of the Internal Revenue Service. We need the information to process your application for employment with the Internal Revenue Service. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally tex returns and return information are confidential, as required by code 6103. The time needed to complete this form will vary depending upon the individual circumstances. The estimated average time to complete this form is 5 minutes. If you have comments concerning the accuracy of this estimate or suggestions for making this form simpler, we would be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.

Form

12884 (Rev. 3-2005)

Catalog Number 30944Z

Department of Treasury — Internal Revenue Service