TeleMainia Phone Actress -

Phone-Actress Affiliate Application

Please fill out all fields, * fields are mandatory

Username: * Username must be at least 5 letters or numbers, and can have only letters and or numbers.

Password:* Password must includes:
a minimum of 8 characters
at least one capital letter
at least one lower case letter
at least one number
at least one special character

Password must includes:
a minimum of 8 characters
at least one capital letter
at least one lower case letter
at least one number
at least one special character

Re-Enter password:*

Legal First Name: Your legal name as it appears on your drivers license, bank account, passport, etc.

Middle Name:

Legal Last Name: Your legal name as it appears on your drivers license, bank account, passport, etc.

Address1:*

Address2:

Country:

City:*

State:*

Zip Code:*

Primary Contact Number: *

Mobile Phone Number:

When you enter your SMS enabled mobile phone number, you are opting-in to receive SMS message updates regarding your application along with instructions to complete your application. Your carrier message and data rates may apply.

E-Mail Address:*

Re-Enter E-Mail:*

Referral Code

Birth Date(mm/dd/yyyy): *

I am 18 Years of Age or Older

Birth Date(mm/dd/yyyy): *

Comments:*

Tell Us About Your Experience and/or Why You Are Interested in Being a Phone-Actress