SpecialtyCare Draft

First name

Last name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

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?

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.