[Your Name]

[Company Name]

[Street Address]

[City, ST ZIP Code]

[Date]

[Recipient Name]

[Title]

[Company Name]

[Street Address]

[City, ST ZIP Code]

Dear [Recipient Name]:

[Applicant Name] has applied for a position with our company and listed previous employment with your company. To ensure that we can give all possible consideration to [Applicant Name]’s application, I am requesting the information below. Any information that you provide will be kept confidential. If you have any questions, please contact me at [phone number]. Thank you for your time in considering our request.

Sincerely,

[Your Name]

[Title]

Position with your company:
Employed from To Starting salary: $ Ending salary: $
Reason for leaving:
Would you rehire? ☐ Yes ☐ No
If no, explain: