| Personal Information |
| Your full legal name: |
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| Last |
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| Maiden |
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| First |
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| Middle |
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| Home Address: |
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| Number and Street |
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| City |
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State
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| Country |
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| Zip Code |
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| Home Phone Number: |
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| E-mail Address: |
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| Employer: |
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| Business Address: |
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| Business Phone Number: |
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| Eligible for tuition reimbursement from employer? |
| Marital Status: |
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| Are you a U.S. Citizen? |
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| Citizen of |
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(If a Resident Alien, send copy of visa card.) |
| Have you taken the TOEFL? |
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| Date of Birth: |
(mm/dd/yy) |
| The following information is optional and is requested for use on federal and state reports as well as institutional research. This information is not used in determination of one's eligibility for admission, nor will it be used in any discriminatory manner. |
| Religious Preference (optional): |
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| Gender (optional): |
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Are you of Hispanic or Latino Origin?
Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race (optional) |
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Select one or more races from the following groups. (optional)
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| Inquiry Information |
| How did you first learn about Clarke University? Check all that apply. |
| Clarke Student |
Clarke Employee, please specify: |
| Clarke Alum |
Employer |
| Family |
Friends |
| College/Job Fair |
Clarke Event, please specify: |
| Clarke Brochure |
Radio |
| Mail |
Newspaper/insert |
| Television |
Billboard |
| Internet |
E-mail |
| P |
N |
| Other, please specify: |
Relative and Referral Information |
| Relatives who are attending, have attended, or are currently employed at Clarke University: |
| 1- Name |
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| Relationship |
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Dates of Attendance /
Employment |
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| 2- Name |
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| Relationship |
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Dates of Attendance /
Employment |
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| 3- Name |
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| Relationship |
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Dates of Attendance /
Employment |
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| List anyone who referred you to Clarke University, including their relationship to the university (alum, current student, friend of the university, etc.): |
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Academic / Program Information |
| Do you plan to enroll as a TimeSaver student? |
| If yes, select the program / major that you are applying for: |
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| Do you plan to attend as a non-traditional, daytime student? |
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| If yes, select the area of interest or major sought: |
| OR |
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| Enrollment Term: |
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| Enrollment Basis: |
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| Enrolling As: |
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| Degree Sought: |
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High School Information |
| 1- Name of High School |
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| City |
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| State |
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| Graduation/GED Date |
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| List all of the colleges and universities you have attended since high school, beginning with the most recent. |
| 1- Name of Institution |
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| Dates of Attendance |
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| Degree(s) |
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| Date Transcript Requested |
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| 2- Name of Institution |
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| Dates of Attendance |
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| Degree(s) |
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| Date Transcript Requested |
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| 3- Name of Institution |
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| Dates of Attendance |
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| Degree(s) |
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| Date Transcript Requested |
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| Will you apply for financial aid? |
| If yes, complete the financial aid application and submit it to the processing center. |
| Where should Clarke mail your statements of account? |
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| Other Address: |
Family Information |
| Spouse's Name (if applicable): |
| First Name |
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| Last Name |
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| Position: |
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| Employer: |
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| Highest Degree Earned: |
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Certification of Application |
| By typing my name below, I certify that the above information is true and that, if admitted to Clarke, I agree to be governed by the regulations, policies and academic standards of Clarke University. |
| Your Name: Date: |
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