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Application for TimeSaver Admission

*Please use Mozilla Firefox or Google Chrome to complete the form below.

Personal Information
 Your full legal name:  
     Last  
     Maiden  
     First  
     Middle  
 Home Address:  
     Number and Street  
     City  

     State

 
     Country  
     Zip Code  
 Home Phone Number:  
 E-mail Address:  
 Employer:  
 Business Address:  
 Business Phone Number:  
 Eligible for tuition reimbursement from employer? 
 Marital Status:  
 Are you a U.S. Citizen?  
     Citizen of  
  (If a Resident Alien, send copy of visa card.) 
     Have you taken the TOEFL?  
 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):  
Gender (optional):  
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)

  

Select one or more races from the following groups. (optional)

  
 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  
     Relationship  
     Dates of Attendance /
     Employment
 
 2- Name  
     Relationship  
     Dates of Attendance /
     Employment
 
 3- Name  
     Relationship  
     Dates of Attendance /
     Employment
 
 List anyone who referred you to Clarke University, including their relationship to the university (alum, current student, friend of the university, etc.):
      
 
Academic / Program Information
Do you plan to enroll as a TimeSaver student?  
     If yes, select the program / major that you are applying for:
      
 Do you plan to attend as a non-traditional, daytime student?
    
     If yes, select the area of interest or major sought: 
       OR
    
 Enrollment Term:  
 Enrollment Basis:  
 Enrolling As:  
 Degree Sought:  

 High School Information
 1- Name of High School  
     City  
    State   
    Graduation/GED Date   
List all of the colleges and universities you have attended since high school, beginning with the most recent.
 1- Name of Institution  
     Dates of Attendance  
     Degree(s)  
     Date Transcript Requested  
 2- Name of Institution  
     Dates of Attendance  
     Degree(s)  
     Date Transcript Requested  
 3- Name of Institution  
     Dates of Attendance  
     Degree(s)  
     Date Transcript Requested  
 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?
    
    Other Address:

Family Information
Spouse's Name (if applicable):
    First Name  
    Last Name  
Position:  
Employer:   
Highest Degree Earned:  

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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