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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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