BPC PROGRAM MEMBER QUESTIONNAIRE
DESIGNED TO ASSIST YOU IN REACHING YOUR GOALS!
Once you've completed this questionnaire, please return it to us through
the upload form found in your member website.
Save the document as: YourNameQuestionnaire.pdf
(i.e. JohnSmithQuestionnaire.pdf)
Name:
Address:
E-mail address (required):
Primary Phone Numbers:
Cell:
Work:
Skype:
Website:
Facebook:
Twitter:
Birthday (mm/dd/yyyy):
Spouse’s Name:
Children’s Names & Ages:
Please take your time to carefully answer and complete each question. This
document is to be returned through the submission form in your Bob Proctor
Coaching member area; no hand written copies please. - Thank you!
“Doing at once what needs to be done
increases the possibility of success.”
- Leland Val Van De Wall
BOB PROCTOR COACHING PROCTOR GALLAGHER INSTITUTE
(800) 871-9715 US: (480) 767-2458 E: ADMIN@BOBPROCTORCOACHING.COM 1
INTRODUCTION
The purpose of this questionnaire is to provide Bob Proctor and his Coaching Team
with information that will give us an understanding of your present situation and
insight into the cause of your present results. You may rest assured that any
information that you provide to the BPC Coaching Team, as well as anything
discussed in person or on the telephone, will be kept in strict confidence.
As you answer each of the questions, we suggest that you view your answers
merely as a gauge of where you are currently – the information is neither good nor
bad, positive nor negative. It is essential that we have a complete understanding of
where you are. You, therefore, must be very candid and honest in your assessment.
PERSONAL INFORMATION
The information that we ask for in this section is general in nature and will better
help us to acquaint ourselves with you:
1. Name two people who have influenced your life the most. Please state their
relationship to you and how they influenced you.
a.
b.
2. If we asked two of your best friends what your greatest strengths and weaknesses
were, what do you believe their answer would be?
Strengths:
Weaknesses:
3. Right-brain people are very creative, frequently impulsive, with high energy and often
deal from an emotional level. Left-brain people have a tendency to be more
analytical, frequently dominant, desiring a fair amount of order in their life. Place an X
under the terminology that best describes you:
Left-Brain Right-Brain Both
4. On a score of 1-10 (with 10 being high), where would your two best friends
score you in your appearance?
BOB PROCTOR COACHING PROCTOR GALLAGHER INSTITUTE
(800) 871-9715 US: (480) 767-2458 E: ADMIN@BOBPROCTORCOACHING.COM 2
5. Place an “X” beside the word(s) that best describes you:
a. Calm and easy going?
b. Sensitive?
c. Sympathetic?
d. Quickly angered and showing your feelings and emotions?
e. You internalize your anger, joy or other feelings?
6. Place an “X” beside the statement that best describes you:
a. You make friends quickly and enjoy being with others socially?
b. You have close intimate friends and generally feel uncomfortable in social
settings?
Much of what we do over the course of the program involves RAISING YOUR LEVEL
OF AWARENESS of your Infinite Potential. It wasn’t all that long ago that a couple
of bicycle mechanics conceived the idea of building a flying machine. That idea
introduced us all to the world of flight. You are capable of far more than you
imagine!
This information is held in strict confidence.
7. Place an “X” beside the words that best describe how you deal with money:
a. Spend it quickly
b. Keep it and bargain a lot
c. Love to earn it
d. Not overly concerned with it
8. What is the most you’ve ever earned in a year?
9. What is your current yearly income?
10. Are you or have you ever been involved in a network marketing company?
If YES…
a. What company are you with?
b. How long have you been involved?
c. What is your current monthly income?
11. What other business or career choices are you interested in exploring?
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12. What personal development programs have you attended in the past?
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BOB PROCTOR COACHING PROCTOR GALLAGHER INSTITUTE
(800) 871-9715 US: (480) 767-2458 E: ADMIN@BOBPROCTORCOACHING.COM 3
PROGRAM OBJECTIVES
Though we assume that one of your program objectives is to increase your income,
we want you to know that this program is holistically based. With that in mind, we
want you to look at your life as a whole and indicate certain areas where you would
like to see improved results: Spiritually, in your relationships, physically, mentally,
educationally, etc. Your goals need to be quantifiable - it’s not enough to say that
you want more money or want to lose weight. You need to work with a specific
objective in mind.
1. Being as specific and brief as possible, describe exactly what you would hope to
accomplish from this year in the Bob Proctor Coaching Program in general?
2. What is your income objective for the year?
3. List, in order of priority, 3 key areas of your life in which you would like to see a marked
improvement - and why.
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4. Please state your level of commitment to this program below.
BOB PROCTOR COACHING PROCTOR GALLAGHER INSTITUTE
(800) 871-9715 US: (480) 767-2458 E: ADMIN@BOBPROCTORCOACHING.COM 4
WHAT’S HOLDING YOU BACK
Knowing that our paradigms make and break us, we want you to be totally honest
with yourself and really think about your habitual behavior and conditioning and how
it affects your life. One of our objectives will be to make you critically aware of this
behavior and assist you in changing it. It’s not possible to get different results
without breaking through some of the limiting beliefs you may have of yourself or
your capabilities.
1. With your program objectives in mind, list the predominant 4 to 6 habits you believe
may be holding you back from achieving the results you desire - and why.
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2. What do you fear and why? (i.e. success, failure, being alone, meeting new people,
etc.)
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BUSINESS HISTORY AND BACKGROUND
1. What is your primary business or job description? Please state it in 25 words or less.
2. On a score of 1-10 (10 being high), what is your level of expertise in your field?
3. Have you ever worked in sales? (Y/N)
4. In one brief sentence, describe your perception of what a salesperson does?
BOB PROCTOR COACHING PROCTOR GALLAGHER INSTITUTE
(800) 871-9715 US: (480) 767-2458 E: ADMIN@BOBPROCTORCOACHING.COM 5
5. Relative to your business or profession, what is the most obvious thing in your mind you
could do to change your results?
6. Do you have your own business?
7. Do you have employees? If yes, how many?
8. Does your business require your presence? Explain why or why not.
9. Who are the superstars in your business?
10. Have you met them? Do you know them?
11. Jay Abraham uses the idea of a “Unique Selling Proposition” or USP, which he defines
as that special thing that is different about you and/or your product or service that
distinguishes you from others. Why do your customers or clients do business with you
as opposed to someone else? Describe your USP?
12. Think of two or three very successful people with whom you are familiar – what is it
about their way of doing business that you admire and would like to make a part of
your habitual behavior?
BOB PROCTOR COACHING PROCTOR GALLAGHER INSTITUTE
(800) 871-9715 US: (480) 767-2458 E: ADMIN@BOBPROCTORCOACHING.COM 6
