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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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