Application Form | Back2Work

Application for Cedar Rapids SVdP Back2Work Program

* Required fields

Please complete the following required fields:

General Information

First Name

Please enter your first name

Last Name

Please enter your last name

Street Address

City, State, Zip

Phone

Date of Birth

Gender

Male Female Other

Race (select all that apply)

African American/Black White Asian Native American Native Hawaiian/Pacific Islander Other

Are you Hispanic or Latino?

Yes No

Household Information

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

Military & Background

Veteran Status

Served Did not serve

If served, Branch

Years Served

Are you a Refugee?

Yes No

Have you experienced Foster Care?

Yes No

Education

Grade Completed

High School Graduate?

Diploma/Equivalency

College

Trades/Apprenticeships

Certificates/Diplomas/Continuing Education

Employment History

Employment History (Most Recent First)

Include: Company name, position, dates worked, and FT/PT/Temp status

Monthly Income from Employment

Legal Background

Criminal Background

Current or Pending Charges

Parole Status

Transportation

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

Financial Status

Work Income (Monthly)

Partner Work Income (Monthly)

SNAP Benefits (Monthly)

Section 8 (Monthly)

Disability (Monthly)

Child Support (Monthly)

Other Income (Monthly)

Do you have a Bank Account?

Yes No

Garnishments

Fines

Credit Issues

Bankruptcy or Debt

Technology Access

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

Health Information

Mental Health Issues

Physical Health Issues

Application Details

Reasons for Applying to the Back2Work Program

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

Trades/Construction Factory Warehouse Retail Food Service Data Entry/Analysis Call Center Health Care Customer Service Sales Automotive Transportation Technical Other

Job Time Preference

Full Time Part Time Either

Authorization

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: April 14, 2026

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