SpecialtyCare Draft

First name

Last name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Phone number in Whatsapp, if different

Name of the Employer trying to charge you fees if you quit*

State where you worked*

Around when did you start working?*

Approximately, what date did you start working? (It does not need to be exact)

Approximate end working date*

Approximately, what date did you stop working? (It does not need to be exact)

Provide a brief summary of the training received*

Amount of the TRAP debt*

Length of required employment period

Has your employer made any attempts to collect?*

YesNoNo, because I didn't leave my position early

If Yes, please explain

Additional comments or questions

If needed, do we have your authorization to share your information with other Attorneys in our network? The shared information will remain confidential within our network of Attorneys.*

YesNo