Request Information

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

*
All fields marked with an asterisk (*) are required.

Personal Information

*

First Name

Please enter a valid First Name

Middle Name

Please enter a valid Middle Name

*

Last Name

Please enter a valid Last Name

Previous Last Name (If different than current Last Name)

Please enter a valid Previous Last Name

*

Create username

*

Create password (Must be a minimum of 7 characters)

*

Confirm password

*

E-mail

Address:

*

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)

*

City

*

State:

*

ZIP Code:

Phone number including area code

*

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

*

Actual or anticipated HS Grad or GED Year

*

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

*

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.

*

1st Choice

2nd Choice

3rd Choice

If you are interested in extracurricular activities, indicate below.

1st Choice

2nd Choice

3rd Choice

*

Date of Birth (mm/dd/yyyy)

January 2019

Sun Mon Tue Wed Thu Fri Sat
01 30 31 1 2 3 4 5
02 6 7 8 9 10 11 12
03 13 14 15 16 17 18 19
04 20 21 22 23 24 25 26
05 27 28 29 30 31 1 2
06 3 4 5 6 7 8 9

Clear

Jan Feb Mar Apr
May Jun Jul Aug
Sep Oct Nov Dec

OK

Cancel

*

Primary Campus

D I S C L A I M E R: The data presented on this page is confidential.

Clear form