CLARION UNIVERSITY OF PA                                                                  

Online CPA Exam Eligibility Program Form                                                           

(Valid for One Semester Only)                                                                            

Please complete the top portion of the form completely.  Use N/A for items that do not apply.  Items with an * are required entries.  Students
participating in the Online CPA Exam Eligibility Program must have a bachelor's degree.  Official transcripts will need to be provided indicating

receipt of a bachelor’s degree.

Last Name*:                 First Name*:                Middle Initial:    

Former Names 

Street Address*:                City*:              

State*:                    Zip*:                        Email Address: 

Birthdate:  (MM/DD/YYYY)     Sex:   Select M F      Ethnicity:   Select White, Non-hispanic Asian or Pacific Islander Black, Non-Hispanic Hispanic American Indian/Alaska Native Prefer not to answer

Daytime Phone Number:        Home Phone Number*:                

PA Resident*:                      Select Yes No      If yes, name of county:           

Do you have a bachelors degree*:            Select Yes No   Note:  A student must have a bachelor's degree to participate in program.

Name of college awarding degree*:       

College GPA:      College Attendance Dates*:      (MM/YYYY - MM/YYYY)

Date degree awarded*:        (MM/YYYY)

  Note:  Official transcripts will need to be provided indicating receipt of a bachelor’s degree.

High School Attended:    Graduation Year: 

High School City and State: 

GED:    Select Yes No               If GED earned, date GED was received: 

Have you attended Clarion University previously*?                Select No Yes

Term for which you are applying*:      Summer           Year for which you are applying*:                
                                                        Fall
                                                        Spring

 Program you are applying for:   Online CPA Exam Eligibility Program

How did you hear about the Online CPA Exam Eligibility Program? Please Select Clarion Website Email Direct Mail Telephone Friend, relative, or colleague Newspaper Search Engine (i.e. Google) Professional Organization Affiliation Other

This form must be completed each semester of enrollment.

This form can only be used for the online CPA Exam Eligibility Program.

By clicking the submit button, you are verifying that the information provided is accurate.