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SIRE'S REGISTERED NAME: _________________________________________________________
EJRTCA'S REGISTRATION NUMBER: _____________________
OWNED BY.....
NAME:____________________________________________________________________________
ADDRESS: ________________________________________________________________________
CITY: _____________________________________________________________________________
STATE: ___________________ ZIP: ____________________ COUNTRY: _____________________
DAM'S REGISTERED NAME: _________________________________________________________
EJRTCA'S REGISTRATION NUMBER: _____________________
OWNED BY.....
NAME: ___________________________________________________________________________
ADDRESS: ________________________________________________________________________
CITY: ____________________________________________________________________________
STATE: _____________________ ZIP: ____________________ COUNTRY: ___________________
DATE(S) BRED: ____________________________________________________________________
DATE WHELPED: ___________________________________________________________________
NUMBER BORN: ______ MALES: __________________ FEMALES: ________________________
Are either the Sire or Dam Registered with any other organizations? If so, please give name
of organization and registration number:
__________________________________________________________________________________
__________________________________________________________________________________
As the owner(s) of the Dam, I (we) hereby certify this information to be true.
Signed: __________________________________________________ Date: ___________________
Signed: __________________________________________________ Date: ___________________
© English Jack Russell Terrier Club Alliance, Inc.
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