Application Form | Back2Work

First Name

Please enter your first name

Last Name

Please enter your last name

Race (select all that apply)

Are you Hispanic or Latino?

Yes No

Household Type

Single Two Adults Two Adults with Children Single with Children

Do you have children under the age of 21?

Yes No

If yes, ages

Housing Status

Please select your housing status

Housing Ownership

Veteran Status

Served Did not serve

Are you a Refugee?

Yes No

Have you experienced Foster Care?

Yes No

Trades/Apprenticeships

Certificates/Continuing Ed

Fluent Languages (Read & Write)

Are you currently working?

Yes No Full Time Part Time

Employment History

Most recent first. Leave rows blank if they do not apply.

Employer

Position

Dates

Full Time / Part Time / Temp

Monthly Income

Employer

Position

Dates

Full Time / Part Time / Temp

Monthly Income

Current or Pending Charges

Do you have a current Driver's License or Iowa ID?

Yes No

Do you have access to a vehicle?

Yes No

Do you use Public Transportation?

Yes No

Work Income (Monthly)

Partner Work Income (Monthly)

Other Income (Monthly)

Do you have a Bank Account?

Yes No

Do you have a Cell Phone?

Yes No

Do you have access to a PC/Computer?

Yes No

Do you have Internet Access?

Yes No

Can you search the internet using a search engine?

Yes No

Can you use a word processor?

Yes No

Are you working with a mental health counselor?

Yes No

Mental Health Issues

Physical Health Issues

Reasons for Applying to the Back2Work Program

What type(s) of job(s) are you interested in finding? (Select all that apply)

Type of work desired

Full Time Part Time

Note: This program is focused on Full Time employment.

Do you have potential barriers to full-time work after the program?

Yes No

Certification: My signature below certifies that all information provided on this enrollment form is accurate to the best of my knowledge.

Type your full name as signature

Today's date: September 23, 2026

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