English Jack Russell Terrier Club Alliance, Inc.

Stud owner to fill out completely, print, sign, and mail to the EJRTCA..........

This is to certify the Bitch:

REGISTERED NAME________________________________________________________

EJRTCA'S REGISTRATION NUMBER:

__________________

_____

OWNED BY.....

NAME______________________________

_____________________________________

ADDRESS

________________________________________________________________

CITY

_____________________________________________________________________

STATE:

_____________________

ZIP:

_______________COUNTRY:

_______________

Was bred to my Stud Dog:

REGISTERED

NAME___________________________________________________________

____

EJRTCA'S REGISTRATION NUMBER:

_______________________

OWNED BY.....

NAME

__________________________________________________________________

ADDRESS

____________________________________________________________________

___

CITY

____________________________________________________________________

STATE:

_____________________

ZIP:

_____________COUNTRY:

______________

____

DATE(S) BRED:

_____________________________________________________________________

____

Are either the Sire or Dam Registered with any other organizations? If so, please

give

name

organization and registration number:

_________________________________________________________________________

As the owner(s) of the Stud, I (we) hereby certify this information to be true.

Signed:

____________________________________________Date:

_____________

___

Signed:

___________________________________________

Date:

_____________

___

Form ej-stud.html Issued 4/8/97 updated 9/8/99, 7/6/05

, 1/1/07