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

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<ul><li><p>7/18</p><p>60 Corporate Woods, Suite 310 PO Box 270453 Rochester, NY 14627-0453 An Equal Opportunity Employer </p><p>University of Rochester </p><p>Tuition Benefits Plan </p><p>TUITION BENEFITS SERVICE CREDIT FORM </p><p>At the University of Rochester, the service requirement for the tuition benefits plan may be met </p><p>by service at another college, university or U of R affiliated teaching hospital, as well as service at a </p><p>member of the controlled group* of the University that offered a tuition benefit plan for which the </p><p>faculty or staff member was eligible. To receive credit for such prior service, please complete the </p><p>following and return to the Office of Total Rewards (Tuitionbenefits@ur.rochester.edu) as soon as possible.</p><p>Name ___________________________________ Employee I.D. #: </p><p>I hereby certify that I was previously employed by the following college(s), university(s), U of R </p><p>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): </p><p>Myself </p><p>Dependent Children </p><p> Name of Institution Dates of Service Type of Service </p><p> From To (Full-time or Part-time) </p><p>______________________ ___________ ___________ ______________ </p><p>______________________ ___________ ___________ ______________ </p><p>______________________ ___________ ___________ ______________ </p><p>______________________ ___________ ___________ ______________ </p><p>_______________________________________ ______________________ </p><p>Signature of Employee Date </p><p>NOTE: Forms must be received no later than 30 days after the start of the course </p><p>*Members of the controlled group of the University of Rochester include: Highland Hospital, Highlands at Brighton, Highlands</p><p>at Pittsford, Highlands Living Center, UR Medicine Home Care (VNS), Visiting Nurse Signature Care, High Tech </p><p>Rochester, Nicholas H. Noyes Memorial Hospital, Jones Memorial Hospital and F.F. Thompson Health System, Inc.</p><p>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: </p></li></ul>