Membership Form

Name: _____________________________________________________

Name (as you would like it to appear on card):


Mailing Address:




City ________________________________State_______Zip_________

Phone _____________________________________________

E-Mail _____________________________________________

Annual Dues: $________
Additional Donation: $_________
Pendant: $__________
Total Enclosed $________

All dues are annual and are due the October 31st of every year.
We reserve the right to deny membership.

Print out and mail with a Check or Money Order to: 
Panthean Temple
POB 111
Derby, CT 06418

If you would like to make a separate donation over the internet,
please send it via PayPal to