BLANKO PENDAFTARAN PESERTA

GOLONGAN PENGGALANG
LOKABINA KARANA ADHIGUNA TAHUN 2019
GUGUSDEPAN BANDAR LAMPUNG 11-033
GUGUSDEPAN BANDAR LAMPUNG 11-034
UNIVERSITAS LAMPUNG
IDENTITAS
PENDAFTAR
Asal Sekolah/Gudep : Nomor kendali pendaftaran (diisi
oleh panitia)
Alamat Sekolah/Gudep :
Telp.
Bina Damping/Pembina : Jabatan NTA
PESERTA LOMBA

No. LKBB Pionering Kreasi Kolone Tongkat Senam Pramuka Solosong Pidato Bilingual Senam Semaphore LKS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Mengetahui Bandar Lampung, 2019
Kamabigus, Petugas Pendaftaran,

*)Catatan : Dapat diperbanyak

 GERAKAN PRAMUKA
GUGUSDEPAN BANDAR LAMPUNG 11-033
GUGUSDEPAN BANDAR LAMPUNG 11-034
UNIVERSITAS LAMPUNG
Sekretariat : Jl. Prof. Dr. Soemantri Brojonegoro No.I Gd GKU Lt .1 Telp. 0858 4006 6670 Gedung Meneng – Bandar Lampung 35145

BIODATA PESERTA

Nama Lengkap : ...............................................................

Nama Panggilan : ............................................................... Pas Foto
Tampat tanggal lahir : ............................................................... 3X4
Jenis kelamin : L/P *)
Gol darah : A / B / AB / O. )
Agama : ...............................................................

Alamat : .................................................................................................
.................................................................................
..................................................................................
Gugusdepan : ..................................................................................................
Pangkalan : ......................................................................................................
Contact Person : .................................................................................................

Pengalaman dikepramukaan
1. .........................................................................................................Tahun...................
2. .........................................................................................................Tahun...................
3. .........................................................................................................Tahun...................
4. .........................................................................................................Tahun...................

Bandar Lampung, 2019

( .........................................................)

*)Foto ditempel
**)Dapat diperbanyak
 GERAKAN PRAMUKA
GUGUSDEPAN BANDAR LAMPUNG 11-033
GUGUSDEPAN BANDAR LAMPUNG 11-034
UNIVERSITAS LAMPUNG
Sekretariat : Jl. Prof. Dr. Soemantri Brojonegoro No.I Gd GKU Lt .1 Telp. 0858 4006 6670 Gedung Meneng – Bandar Lampung 35145

BIODATA PEMBINA PENDAMPING

Nama Lengkap : ...............................................................

Nama Panggilan : ............................................................... Pas Foto
Tampat tanggal lahir : ............................................................... 3X4
Jenis kelamin : L/P *)
Gol darah : A / B / AB / O. )
Agama : ...............................................................

Alamat : .................................................................................................
.................................................................................
.................................................................................
Gugusdepan : ...................................................................................................
Pangkalan : ...................................................................................................
Contact Person : ................................................................................................

Pengalaman dikepramukaan
1. .........................................................................................................Tahun...............
2. .........................................................................................................Tahun...............
3. .........................................................................................................Tahun...............
4. .........................................................................................................Tahun...............

Pengalaman Organisasi lain

1. .........................................................................................................Tahun...................
2. .........................................................................................................Tahun...................
3. .........................................................................................................Tahun...................
4. .................................................................................................Tahun...................

Bandar Lampung, 2019

( .........................................................)

*)Foto ditempel
**)Dapat diperbanyak