Background Picture: Copyright© All rights reserved, by Laura Alexander
             EJRTCA Membership Application
                      English Jack Russell Terrier Club Alliance, Inc.
               An Official Club for the Short-Legged Jack Russell Terrier
               14405 Highway 98, Magnolia, AR 71753
                  Phone: (318) 286-7151    Email:
ejrtlady@gmail.com
Fill out completely, print and mail to the EJRTCA.

NAME: ________________________________________________________________________

ADDRESS: _____________________________________________________________________

CITY: ___________________________________STATE: ____________  ZIP: _______________

COUNTRY: ____________________________________________________________________

Telephone/Fax/Internet Information

HOME PHONE: _________________________________________________________________

CELL PHONE: __________________________________________________________________

BUSINESS PHONE: ______________________________________________________________

FAX NUMBER: __________________________________________________________________

EMAIL ADDRESS: _______________________________________________________________

WEBSITE NAME: ________________________________________________________________

WEBSITE ADDRESS: _____________________________________________________________

Type of Membership Requested.....Make Checks payable to EJRTCA
NEW:  $20.00 (yearly)
RENEWAL:  $20.00 (yearly)
ADDRESS CHANGE:  $10.00      
BREEDER REFERRAL:  $25.00 (yearly)
Please check: Payment enclosed (     )      Payment submitted On Line (     )
                                 Fees subject to change.

I hereby apply for membership in the English Jack Russell Terrier Club Alliance Inc. and agree to abide by the
objectives and purposes stated in the EJRTCA Constitution and By Laws.

Sign: _________________________________________  Date___________________________  

Form ej-membership.html Issued 4/8/97 updated 9/8/99, 7/6/05. 1/01/07
© English Jack Russell Terrier Club Alliance, Inc.