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

USULAN PEMBERIAN TANDA PENGHARGAAN GERAKAN PRAMUKA

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

1. Tanda penghargaan berupa : ........................................................................

2. Nama lengkap : ....................................................(Putera/Puteri)
3. Tempat dan tanggal lahir : ........................................................................
4. Jabatan dalam kepramukaan : ........................................................................
5. Jabatan pokok di luar kepramukaan : ........................................................................
6. Tanggal diangkat/dikukuhkan
sebagai anggota Gerakan Pramuka : ........................................................................
7. Bangsa : Indonesia
8. Agama : ........................................................................
9. Golongan darah : ........................................................................
10. Nama Isteri/Suami : ........................................................................
11. Alamat : ........................................................................
...............................Tel/Fax.............................
Hp………………….Email…………………
12. Pendidikan
a. Umum
1) SD ....................................................................................................................
2) SMP .................................................................................................................
3) SMA ................................................................................................................
4) S1 ....................................................................................................................
5) S2 ....................................................................................................................
6) S3 ....................................................................................................................

b. Kepramukaan
1) ...........................................................................................
2) ...........................................................................................
3) ...........................................................................................
4) ...........................................................................................
5) ..........................................................................................
6) ..........................................................................................

13. Syarat-syarat yang telah dipenuhi untuk menerima tanda penghargaan yang diusulkan:
a. ........................................................................
b. ........................................................................
c. ........................................................................
d. ........................................................................
e. ........................................................................
f. ........................................................................
g. ........................................................................
14. Riwayat jabatan dalam kepramukaan
(Dapat diisi di kertas lain)
Dari
Jabatan tgl/bulan/tahun Tempat Keterangan
s/d tgl/bulan/tahun
a. ............................................... ..................................
........... s.d ...........
.
b. ............................................... ..................................
........... s.d ...........
.
c. ............................................... ..................................
........... s.d ...........
.
d. ............................................... ..................................
........... s.d ...........
.
e. ............................................... ..................................
........... s.d ...........
.

15. Uraian perbuatan, perilaku dan tindakan yang menonjol dan patut menjadi keteladanan :
(Dapat diisi di kertas lain)
 ...........................................................................................
 ...........................................................................................
 ...........................................................................................
 ...........................................................................................
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.

17. Keterangan-keterangan lain yang perlu diberikan :

............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................

………, ………………………. 2024

Pengusul,
Kwartir Cabang
Gerakan Pramuka...............................
Ketua,

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