Become a Member

Thank you for your interest in joining MAGIC! Please fill out the application below. After hitting submit, you will be prompted to pay via PayPal. If you prefer to pay by check, please submit your payment to:

MAGIC Office
P.O. Box 24475
Minneapolis, Minnesota 55424:

New Membership Application

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Name *

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Last

Credentials *

Preferred Mailing Address *

Home Office

Business Address *

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City

State

Zip Code

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Cell Phone *

Office Phone *

Email *

Home Address *

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State

Zip Code

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Home Phone *

Personal Email *

Medical Directors please complete this section.

Please list the name(s) and location(s) of the facilities where you serve as medical director: Attach a separate page if necessary.

Facility Address *

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State

Zip Code

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Administrator's Name *

First

Last

Phone Number *

Elected *

Date *

Facility Name *

Facility Address *

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State

Zip Code

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Administrator's Name *

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Last

Phone Number *

Administrator's Name *

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