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If you would like to receive a Clark State information packet, please complete the following form.

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Personal Information

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First Name

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Middle Name

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Last Name

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Previous Last Name (If different than current Last Name)

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E-mail

Address:

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Address line 1

Address line 2 (Do not put more than 1 street address, use only if your address will not fit on line 1)

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City

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State:

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ZIP Code:

Phone number including area code

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County (All Ohio and some Indiana counties are listed, everyone else should use "Other County" from the bottom of the list)

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Actual or anticipated HS Grad or GED Year

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What type of student will you be when you start at Clark State?

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Anticipated Entry Term

Indicate which majors you are interested in below. Departmental certificates are denoted with a DC and are not eligible for federal financial aid.

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1st Choice

2nd Choice

3rd Choice

If you are interested in extracurricular activities, indicate below.

1st Choice

2nd Choice

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Date of Birth (mm/dd/yyyy)

October 2018

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Primary Campus

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