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 . If you prefer to pay by check, please submit your payment to:

MAGIC Office
PO Box 367
Rosemount, MN 55068

New Membership Application

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Name *

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Last

Credentials *

Preferred Address *

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City

State

Zip Code

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Cell Phone *

Email *

Medical Directors please complete this section.

Please list the name(s) and location(s) of the facilities where you serve as medical director.

Facility Address *

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State

Zip Code

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Administrator's Name *

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Last

Phone Number *

Elected *

Date *

Facility Name *

Facility Address *

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City

State

Zip Code

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Administrator's Name *

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Last

Phone Number *

Administrator's Name *

Submit