Request Information

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

If you are interested in extracurricular activities, indicate below.

1st Choice

2nd Choice

3rd Choice

*

Date of Birth (mm/dd/yyyy)

January 2021

Sun Mon Tue Wed Thu Fri Sat
53 27 28 29 30 31 1 2
01 3 4 5 6 7 8 9
02 10 11 12 13 14 15 16
03 17 18 19 20 21 22 23
04 24 25 26 27 28 29 30
05 31 1 2 3 4 5 6

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