Application for Graduate Admission

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Personal Information
 Your full legal name:  
     Previous name  
 Home Address:  
     Number and Street  


     Zip Code  
 Home Phone Number:
(If applicable)
 Cell Phone Number:  
 Home E-mail Address:  
 Business Address:  
 Business Phone Number:  
 Business E-mail Address:  
 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)

Yes    No

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 or Flyer  Radio
     Mail  Newspaper/insert
     Television  Billboard
     Internet  E-mail
     P  N
     Other, please specify: 
Referral Information
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
 Select the graduate program that you are applying for:
 Enrollment Term:  
 Enrollment Basis:  
 What goals are you pursuing that require this level of education?
List all of the colleges and universities you have attended since high school, beginning with the most recent. Include date(s) of graduation or anticipated date of graduation, and any degree(s) received or expected.
 1- Name of Institution  
     Dates of Attendance  
     Graduation Date  
     i.e. bachelor of arts in education
     Date Transcript Requested  
 2- Name of Institution  
     Dates of Attendance  
     Graduation Date  
     Date Transcript Requested  
 3- Name of Institution  
     Dates of Attendance  
     Graduation Date  
     Date Transcript Requested  
 Graduate Entrance Examination(s) you have taken:
     1- Test  
     2- Test  

 Financial Aid Information
 Will you apply for financial aid?  
     If yes, complete the FAFSA and have it sent to Clarke University.
 Where should Clarke mail your statements of account?
    Other Address:

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:  

**Clarke University does not discriminate on the basis of age, sex, race, color, national or ethnic origin, or handicap in its educational programs, admissions policies, employment practices, financial aid, athletics, or other university-administered programs. Clarke University complies with all pertinent state and federal regulations concerning affirmative action, non-discrimination, and equal employment opportunity.


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