Lampiran surat usul nomor: ........................................

USUL PEMBERIAN TANDA PENGHARGAAN GERAKAN PRAMUKA

BAGI ANGGOTA DEWASA GERAKAN PRAMUKA DAN
ORANG DEWASA DI LUAR GERAKAN PRAMUKA

KEPUTUSAN KWARNAS NOMOR 175 TAHUN 2012

Kwartir Daerah : Jawa Timur

Kwartir Cabang : Ponorogo
1. Tanda penghargaan berupa : Pancawarsa I
2. Nama lengkap : Samsudin Putra/Putri *)
3. Tempat dan tanggal lahir : Ponorogo, 17 Agustus 1988
4. Jabatan dalam kepramukaan : Pembina Gudep / Sekretaris Kwaran Mlarak
5. Jabatan pokok di luar kepramukaan : Guru
6. Tanggal diangkat/dikukuhkan
sebagai anggota Gerakan Pramuka : ....................................................................................
7. Bangsa : Indonesia
8. Agama : Islam
9. Golongan darah : B
10. Nama Istri/Suami *) : Shofiyatul Hidayah
11. Alamat : Bandar 01/04 Karangjoho Badegan
..................................................Tel/fax........................
Hp 0856 3426 090 Email. samsudinspd02@gmail.com

12. Pendidikan
a. Umum
1) SDN Mojomati .......................................................................................................................
2) SMP Negeri 2 Jetis .............................................................................................................
3) SMA Muhammadiyah 1 Ponorogo..........................................................................................
4) S1 PTE - Universitas Negeri Surabaya ...................................................................................
5)
S S2…………………………………………………………………………………………….
6) S3…………………………………………………………………………………………….
1)

Kepramukaan
1) KMD Pusdiklatcab Amarta Kwarcab Ponorogo 2016 di PP Sulamul Huda Mlarak.............
2) KML Pusdiklatcab Amarta Kwarcab Ponorogo 2018 di Kwarcab Ponorogo ......................
3) KPD Kwarda Jawa Timur 2021 di Kwarcab Ponorogo ........................................................
4) ............................................................................................................................................
5) ............................................................................................................................................

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 6) ............................................................................................................................................
7) ............................................................................................................................................
8) ............................................................................................................................................
9) ............................................................................................................................................
10) ............................................................................................................................................

13. Syarat-syarat yang telah dipenuhi untuk menerima tanda penghargaan yang diusulkan:
a. ............................................................................................................................................
b. ............................................................................................................................................
c. ............................................................................................................................................
d. ............................................................................................................................................
e. ............................................................................................................................................
f. ............................................................................................................................................
g. ............................................................................................................................................
h. ............................................................................................................................................

14. Riwayat jabatan dalam kepramukaan

(Dapat diisi di kertas lain)
Dari
Jabatan Tempat Keterangan
tgl/bulan/tahun
s/d
tgl/bulan/tahun
a. Pembina Pendamping 2016-2017 SMK N 1 Mlarak
b. Pembina Gudep 2017-2022 SMK N 1 Mlarak
c. Andalan Kwaran Mlarak 2017-2020 Kwaran Mlarak
d. Sekretaris Kwaran Mlarak 2022-2025 Kwaran Mlarak
e.
f.
g.
h.
i.
j.
k.

15. Uraian perbuatan, perilaku dan tindakan yang menonjol dan patut menjadi keteladanan:
(dapat diisi di kertas lain)
Semangat, Suka Belajar, ...............................................................................................................
…....................................................................................................................................................
.......................................................................................................................................................

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16. Tanda penghargaan/kehormatan dari Gerakan Pramuka dan di luar Gerakan Pramuka yang telah
dimiliki (dibuktikan dengan foto copy ijazah, sertifikat atau lainnya):
Jenis/macam Dari Tgl Penerimaan Keterangan
a.
b.
c.
d.
e.
f.
g.

17. Keterangan-keterangan lain yang perlu diberikan:

Pernah mengabdi di 3T dan membina pramuka di SMK Negeri Tempeh Lumajang Jatim,
SMK Negeri 4 Manokwari Papua Barat, SMK Negeri 1 Halmahera Barat Maluku Utara
.......................................................................................................................................................
…....................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

*) Coret yang tidak perlu.

Ponorogo, 20 Mei 2022

Kwartir Cabang
Gerakan Pramuka Ponorogo
Ketua Ketua Dewan Kehormatan Cabang

Hj. Lisdyarita, S.Sos ………………………..

Mengetahui Menyetujui
Gerakan Pramuka Ketua Dewan Kehormatan Daerah
Kwartir Daerah Jawa Timur
Ketua Harian,

Prof. Dr. Suyatno, M.Pd. Drs. H. Bambang SW