EMPLOYEE NAME:

Tier 4 – Student Declaration Form

CHECKER NAME: CHECKER SIGNATURE: DATE OF FORM COMPLETION:
United Kingdom Rachel Evans 11/08/23

Amazon has a legal obligation to ensure that all employees have the right to work in the UK BEFORE they commence employment and that they work
at all times within any restrictions prescribed by their visa. It is the responsibility of Tier 4 student workers and their line managers to ensure
compliance with any visa conditions.

A student that is permitted to work in the UK will have a clear endorsement that states the number of hours per week they are permitted to
work. If permission to work is not stated in their passport or biometric residence permit, the student is not permitted to work.

TIER 4 RESIDENCE PERMITS CONTAIN THE FOLLOWING DECLARATION:

Parts 1 and 2 of this form must be completed by the Tier 4 student worker and provided to the Right to work checker

1. EVIDENCE OF TERM AND VACATION DATES or CONFIRMATION OF END OF STUDY:

This form must be provided in addition to actual ‘Proof from place of study showing term dates’, ‘Confirmation of End of Study’ or
‘Confirmation of Work Placement’ as referenced in the Right to Work Checklist

Studying at (institution name)

Degree Program and full course name
☐ Undergraduate
☐ Postgraduate
Level
☐ Research (PhD)
☐ Other – please specify
Please note: Courses below degree level may have a 10 hour per week limit, and some Tier 4 visas (e.g. issued for part-time courses) may specify that no
work is permitted

Please detail any other work (paid or unpaid) completed at Amazon or Elsewhere
I am working with a with a sports direct as a part-time and I get paid for it.

Term Dates
Undergraduate students on a degree programme with standard college term. Please enter TERM TIMES NOT VACATION TIMES
– The following dates apply (record for entirety of study/multiple years of study, when possible):
‌Academic Year Autumn Term* Spring Term* Summer Term*
(YYYY – YYYY) (DD-MMM-YYYY to DD-MMM-YYYY) (DD-MMM-YYYY to DD-MMM-YYYY) (DD-MMM-YYYY to DD-MMM-YYYY)

*Dates inserted above will be verified against the term date evidence provided by the employee.
NOTE THAT POSTGRADUATE DEGREE PROGRAMMES OFTEN HAVE DIFFERENT TERM DATES TO STANDARD
UNIVERSITY TERM DATES, PLEASE CONSIDER THIS CONDITION WHEN OBTAINING EVIDENCE

Confirmation of Student not Presently in Academic Study

Undergraduate students on a degree program that has fully ended or are on a full-time work placement whilst their Tier 4 Permit remains
valid – The following indicates the end of the period of study/work placement period as confirmed by the University:

Amazon Confidential
Last Updated 11 August 2023
Tier 4 – Student Declaration Form
United Kingdom

‌Academic Year End of Study Date**

(YYYY – YYYY)

2022 2023 Expected end date: (

‌Academic Year Work Placement Begins** Work Placement Ends**

(YYYY – YYYY) (DD-MMM-YYYY) (DD-MMM-YYYY)

Depend on Offer received 6/12 months

**Dates inserted above will be verified against the confirmation of end of study/work placement letter provided by the employee.

2. STUDENT DECLARATION:

 I understand that I am permitted to work on a restricted basis normally up to a maximum of 10/20 hours per week during term-time
(recorded as Monday to Sunday) and full-time during
EMPLOYEE NAME:
holiday periods or after my course has officially ended,
provided my Tier 4 visa is still valid. CHECKER NAME: CHECKER SIGNATURE: DATE OF FORM COMPLETION:
 I understand that I must update Amazon immediately if Racheal Evans
my Tier 4 visa is cancelled or if I rely upon a different
visa type in order to legally work in the UK.
 I understand my responsibility in relation to this and I will not accept more than the maximum total number of weekly hours permitted by
my Tier 4 visa.
 I understand that any work (or voluntary work) I have outside of Amazon also counts towards this limit.
 I understand that any breach of my visa conditions (e.g. working more than 20 hours per week during term-time) is considered a serious
immigration offence. I further understand that any action taken by the Home Office as a consequence of my working illegally may result in
my visa being curtailed and must be declared on any future UK visa applications.
 I understand that it is my responsibility, if I have any questions regarding my right to work in the UK, to seek advice and check with UK
Visas & Immigration.
 I understand that, if I change my course of study or leave my course of study early, I must inform Amazon immediately, so that my ability
to work in the UK can be reviewed.

Name
Signature

Date

For action by [Local HR] / Right to work checker

You are required to review and retain this form and evidence of the Tier 4 student worker’s term and holiday dates as part of the pre-employment Right
to Work (RTW) check using the Right to Work Checklist

Scanned copies of the completed RTW checklist and RTW evidence, including this form and additional evidence of term and holiday dates, should be
attached to the TT before sending to HRS Eligibility Team.

Please note:
 Without evidence of term and holiday dates that cover the entire period of employment, the RTW check will not provide Amazon with a statutory
excuse against any Civil Penalty Liability.
 Unless the term date evidence covers the full duration of the Tier 4 student worker’s course of study, it will need to be reviewed and updated on
an annual academic year basis. Local HR is responsible for carrying out this repeat check when required.
 Having evidence of the Tier 4 student worker’s term dates will also make it easier for you to know when they are permitted to work part-time (20
hours per week Monday to Sunday) or full-time.
 Please ensure that you check with the Tier 4 student worker whether they have any other work or voluntary work commitments outside of
Amazon during the period of their employment with Amazon.

Amazon Confidential
Last Updated 11 August 2023