(City, State, Zip)
RE: (Name of Church Member)
On (date), I was informed orally by (name) that I was not to return to work because I would not work on the Sabbath, which I observe from Friday sundown to Saturday sundown. I requested a written notice, but it was not given to me. Since I received nothing in writing, I returned to work on, and, but was prevented from going to work by ______________________.
In lieu of a written notice but in harmony with the oral statements, I shall assume that I was dismissed because of my religious observance and practice.
Religious Liberty Department