I hereby present the following terrier for EJRTCA registration:

    TERRIER'S NAME: ____________________________________________________
          BORN: ________________________ SEX:  []Male   []Female   []Spayed/Neutered
    HEIGHT: ___________inches. (measure from floor to top of withers)
    COAT:   []Smooth   []Broken   []Rough   
    COAT COLOR: []White/Brown   []White/Black   []Tri color   []Other: ___________
    EJRTCA Litter Registration Number: ____________________________________

    Information on the Sire:
    Name: ____________________________________ EJRTCA Reg. # ____________
    Height: __________ inches at withers,   Coat    []Smooth   []Broken   []Rough
    Coat Color:   []White/Brown   []White/Black   []Tri color   []Other:_________________

    Owner: _________________________________________________________________

    Address: ________________________________________________________________

    City: _________________________State: ______ Zip: _______ Phone: _____________

    Information on the Dam:
    Name: _____________________________________EJRTCA Reg. # ________________
    Height: __________ inches at withers,   Coat    []Smooth   []Broken   []Rough
    Coat Color:   []White/Brown   []White/Black   []Tri color   []Other: _________________

    Owner: _________________________________________________________________

    Addres _________________________________________________________________

    City: _________________________ State: ______  Zip: ________Phone: ___________
         
Terrier owned by...

    Name: _________________________________________________________________

    Address: _______________________________________________________________

    City: ___________________________ State: ______ Zip: _______Country:__________

    Home Phone: _____________________________  EJRTCA Member #: ____________

    Email: __________________________________________________________________

    Owner's Signature: ____________________________________   Date: ____________
    © English Jack Russell Terrier Club Alliance, Inc.
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