BERITA ACARA
PELANTIKAN PENEGAK BANTARA
Nama : .........................................................................................................
Tempat, Tanggal Lahir : .........................................................................................................
Sangga : .........................................................................................................
Ambalan : .........................................................................................................
Yang Melantik,
Nama : .........................................................................................................
No SBH : .........................................................................................................
Semarang, .................................
Yang Melantik Yang Dilantik
Pembina Gudep...............
(.................................................) (.................................................)
No SHB.....................................