Our Valued Client Survey

Providing World Class Service to you is our goal, period. In order to do so, we believe that nurturing a relationship of trust and depth is important. Please complete the following questionnaire and survey so that we may learn more about you, and keep in the forefront of our vision, ways to support you and continually honor your needs. The information you will provide for us in this form will be treated with the highest care and confidence.

 

Name & Birthday: ______________________________________

Spouse’s (or Significant Other’s Name) & Birthday:

______________________________________________________

Email Address_______________________ (work or personal)

Wedding Anniversary: __________________________________

House Purchase Date: ____________________________________

Please check the following items so we can get to know you better:

What activities do you like to do? Please write in the initials of who likes what. 

Put F it’s something you do as a family:

___ Going Out for Ice Cream ____ Working Out

___ Going to the movies ___ Ice skating ____Roller Skating

___ Golf ___ Bowling ___ Mini-golf ____Going for Coffee or Tea

___ Renting movies ___ Outdoor activities: Please list: __________

______________________________________________________

______________________________________________________

Where do you like to eat:

___ Pizza Where? _______________________________________

___ Burgers Where? _____________________________________

___ Fine dining Where?___________________________________

___ Italian Where?_______________________________________

___ Mexican Where?_____________________________________

___ Oriental Where?_____________________________________

___ Other(s): __________________________________________

Children’s Names & Date of Birth:

1. __________________________ Date of Birth___________

2. __________________________ Date of Birth___________

3. __________________________ Date of Birth___________

4. __________________________ Date of Birth___________

5. __________________________ Date of Birth___________

Please indicate the interests and activities in which you and/or your spouse/partner 

enjoy participating in on a regular basis:

Charities Volunteer Power Boating  Sailing Jogging Walking Snow Skiing Water Skiing Electronics 
Hunting Shooting Hiking Crossword  Tennis Bowling Camping Fishing Puzzles RE Investments
Children Grandchildren Needlework  Motorcycles RV’s Music Reading Nations Heritage 
Sewing Automotive Work  Bible/Devotionals Household Pets Outdoor Gardening Gourmet Cooking
Photography Cultural Arts Crafts  Fine Arts/Antiques Foreign Travel House Plants Wines
Coin & Stamps Collectibles  Stock/Bonds Veterans Programs Sweepstakes Home Video Games
Health Foods/Vitamins  Knitting Wildlife/Environment Career Activities Computers Science/New Tech.
Physical Fitness Fashion Clothing Workshop Capital/Money making Science Fiction
TV/Sports Bicycling Golf  Self-

Other:_______________________________________________________

From the above list, please indicate the five most important activities for :

YOU                                               SPOUSE

1. ____________________________ 1. _______________________________

2. ____________________________ 2. _______________________________

3. ____________________________ 3. _______________________________

4. ____________________________ 4. _______________________________

5. ____________________________ 5. _______________________________

 

Music you enjoy:

Motown Country Nature Sounds Jazz

New Age Classical Top 40 Rhythm & Blues

Folk Celtic Rap Heavy Meta;

Other______________________________

Are there any special upcoming events for you and/or your family (i.e. graduation, wedding, births,

retirement, vacations?)_________________________________________________________

Thank you for helping us to serve you better.

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