Client Satisfaction Survey
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1. Default Section

1. Please rate your level of agreement with the following statements

	Strongly Agree	Agree	Agree Somewhat	Disagree
I deliverd on what I promised.	Please rate your level of agreement with the following statements I deliverd on what I promised. Strongly Agree	I deliverd on what I promised. Agree	I deliverd on what I promised. Agree Somewhat	I deliverd on what I promised. Disagree
I was accessible when you needed to contact me.	I was accessible when you needed to contact me. Strongly Agree	I was accessible when you needed to contact me. Agree	I was accessible when you needed to contact me. Agree Somewhat	I was accessible when you needed to contact me. Disagree
I listend.	I listend. Strongly Agree	I listend. Agree	I listend. Agree Somewhat	I listend. Disagree
You are willing to recommend me to others.	You are willing to recommend me to others. Strongly Agree	You are willing to recommend me to others. Agree	You are willing to recommend me to others. Agree Somewhat	You are willing to recommend me to others. Disagree
You would use me again if you needed an agent.	You would use me again if you needed an agent. Strongly Agree	You would use me again if you needed an agent. Agree	You would use me again if you needed an agent. Agree Somewhat	You would use me again if you needed an agent. Disagree

2. If you were in charge of my business, what's one thing you'd change?

If you were in charge of my business, what's one thing you'd change?

3. What did I do well?

What did I do well?

4. May I include your comments in my marketing materials

May I include your comments in my marketing materials Yes

No

Yes, but don't use my name.

5. Please update me with your most current information:

Please update me with your most current information: Name:
Address:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

6. I'd like to keep track of those dates that are important to you (The format of this survey makes me include the year, I won't tell anyone. But just so we are on equal playing ground, I was born in 1965!):

	MM		DD		YYYY
Your Birthday	I'd like to keep track of those dates that are important to you (The format of this survey makes me include the year, I won't tell anyone. But just so we are on equal playing ground, I was born in 1965!): Your Birthday Month	/	Day	/	Year
Your Anniversary	Your Anniversary Month	/	Day	/	Year
Your spouses Birthday	Your spouses Birthday Month	/	Day	/	Year

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