Successful, Self-Employed & Disabled SHOUT-OUT Request

Thank you for requesting a shoutout for yourself or your disabled owned business or non-profit on an upcoming episode of the  Successful, Self-Employed & Disabled Podcast.

Please submit this from once per season!  If you do not receive a shout-out by the end of the current season (each season's last episode drops the Tuesday before Memorial Day in the United States) you may resubmit the following season (if we continue the shout-out program).

You will receive only one shout-out during the entire run of the podcast.  Once you have heard your shout-out, there is no need to request another.

Duplicate entries will be flagged and will be disqualified to receive a shout-out.  

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Email *
Your name *
Enter your name as you wish it to be read on the podcast.
Your name phonetically *
please spell out your name phonetically to increase the chances II will pronounce it correctly on the show.
Are you authorized by the disabled owned business or non-profit to market the biasness or non-profit on behalf of the business or non-profit? *

What is the name of your disabled owned business or non-profit?

Provide a link to your disabled owned business or non-profit?


This can be a link to a website, a social media profile (LinkedIn or Facebook), YouTube channel or anything else that will help us verify this is a legitimate business or non-profit. 

Choose your shout-out:


CHOOSE ALL THAT APPLY; Your shout-out will sound like this “This episode we are giving a shout-out to <INSERT YOUR NAME> of <INSERT BUSINESS/NON-PROFIT NAME> and they are….


I understand that by submitting a shout-out request to the Successful, Self-Employed & Disabled Podcast neither the Successful, Self-Employed & Disabled Podcast or #DefineYourself guarantees that I will hear a shout-out of my business on a future episode of the Successful, Self-Employed & Disabled Podcast.


I understand that it is my responsibility to listen for my shoutout on a future episode of the Successful, Self-Employed & Disabled Podcast#DefineYourself may not give me advance notice or inform me after my business received an shout-out on an episode of the podcast.


By electronically signing this form, I am confirming that everything I have submitted on this form is accurate and that I do have permission to market/promote the disabled-owned business or non-profit that I desire to have a shout-out given to on a future episode of the Successful, Self-Employed & Disable Podcast. 


eSign this form by typing your name below 

A copy of your responses will be emailed to the address you provided.
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