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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