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Six Minutes to Success

Give Bob Proctor 6 minutes of your life everyday and he will help you achieve your goals. This daily 6 minute video will help you stay focused, educated, and motivated.

Your Information

First Name*

Last Name*

Company

Address*

City*

Province*

Postal Code*

Country*

Email*

Day Phone*

Evening Phone

*Course Date:

What is the best way to contact you to arrange for your interview?

Check all that apply.

	Daytime Phone
	Evening Phone
	E-mail

How did you hear about this event?

Did someone Refer you to this course (please provide their name):

If you have a Ticket, please enter in the ticket number below.

What changes would you like to make in your life?*

What are your expectations for this program?*

If this seminar fulfills your expectations are you willing to carrying on with our programs?

	yes
	no

If yes, why? and if no, why not?

Other comments...

Please send an invitation to my family and friends

If you would like us to send an invitation to your family and friends for this event, please list their names and email addresses in the space provided.

Are you planning to attend with your spouse?

If you are planning to attend with your spouse, please include their name here so that you are in the same course. (Please ensure your spouse also submits their own form in addition to this form.)