You will want to format the letter into one paragraph - I broke it up like this due to the personal choice you will need to make in the Wording of the letter.
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DATE OF LETTER HERE
Dear (Potential Employer),
Thank you for the potential job opportunity you have offered to me. I regret to say that at this time I must decline due to personal reasons (if you want, be specific here).
HERE YOU NEED TO CHOOSE ONE OF THESE SENTENCES, NOT BOTH*
a) I would like to request that you keep my information on file so that you can contact me about positions available within your organization at a later time.
OR
b) I respectfully request that you remove my name from the list of applicants.
I would like to thank you for your time and attention to this matter.
Sincerely,
YOUR NAME HERE
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