university of rochester tuition benefits ?· 7/18 60 corporate woods, suite 310 · po box 270453...

Download University of Rochester Tuition Benefits ?· 7/18 60 Corporate Woods, Suite 310 · PO Box 270453 ·…

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  • 7/18

    60 Corporate Woods, Suite 310 PO Box 270453 Rochester, NY 14627-0453 An Equal Opportunity Employer

    University of Rochester

    Tuition Benefits Plan

    TUITION BENEFITS SERVICE CREDIT FORM

    At the University of Rochester, the service requirement for the tuition benefits plan may be met

    by service at another college, university or U of R affiliated teaching hospital, as well as service at a

    member of the controlled group* of the University that offered a tuition benefit plan for which the

    faculty or staff member was eligible. To receive credit for such prior service, please complete the

    following and return to the Office of Total Rewards (Tuitionbenefits@ur.rochester.edu) as soon as possible.

    Name ___________________________________ Employee I.D. #:

    I hereby certify that I was previously employed by the following college(s), university(s), U of R

    affiliated teaching hospital(s) or member of the Universitys controlled group* where I was eligible for a tuition benefit plan which covered (check all that apply):

    Myself

    Dependent Children

    Name of Institution Dates of Service Type of Service

    From To (Full-time or Part-time)

    ______________________ ___________ ___________ ______________

    ______________________ ___________ ___________ ______________

    ______________________ ___________ ___________ ______________

    ______________________ ___________ ___________ ______________

    _______________________________________ ______________________

    Signature of Employee Date

    NOTE: Forms must be received no later than 30 days after the start of the course

    *Members of the controlled group of the University of Rochester include: Highland Hospital, Highlands at Brighton, Highlands

    at Pittsford, Highlands Living Center, UR Medicine Home Care (VNS), Visiting Nurse Signature Care, High Tech

    Rochester, Nicholas H. Noyes Memorial Hospital, Jones Memorial Hospital and F.F. Thompson Health System, Inc.

    Name: 1: 2: 3: 4: From 1: From 2: From 3: From 4: To 1: To 2: To 3: To 4: Fulltime or Parttime 1: Fulltime or Parttime 2: Fulltime or Parttime 3: Fulltime or Parttime 4: Check Box1: Check Box2: Text3:

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