Witness Statement Form

NOTE TO ASSOCIATE: Thank you for taking the time to complete this Witness Statement Form. The information you provide will help us to thoroughly investigate the issue that has been brought to our attention. Please indicate on this form below, in Section II, exactly what you saw, heard, and know about the issue you are providing this statement about.

SECTION I: INFORMATION ABOUT THE PERSON MAKING THIS STATEMENT

Name

First NameLast Name

Department/Position

Site/Code:

Home Address, City, State, Zip

Home Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

SECTION II: WITNESS STATEMENT

Describe in your own words, what happened and what you observed. Please make sure to cover the following points below:

Please list any witnesses or individuals who may have information relevant to this investigation.

ACKNOWLEDGEMENT

Amazon values the integrity of the investigation process and the importance of conducting an investigation that is timely, thorough, and accurate. Amazon, its supervisors, and HR respect the sensitive and personal nature of the investigation and intend to keep the investigation as confidential as possible, limiting the disclosure of information to only those people who have a legitimate reason to know.

I understand this statement will be considered part of the official investigation and that this statement I have provided is an honest and accurate account of the case to the best of my knowledge. I further understand that as an Amazon.com associate that I am subject to Amazon’s Code of Ethics and am expected to fully cooperate in all investigations. I understand that intentionally concealing or withholding relevant information or providing purposefully or recklessly false or misleading information, or interfering with, impeding, or undermining the investigation may result in corrective action up to and including termination of employment.

Employee Name

Date

Signature

Signature:

For Internal Regional Use Only