Submit request for assistance – Nirmol Bangladesh

📝 Public & Member Application

Request for Assistance & Support

Nirmol Bangladesh provides transparent assistance for poor, needy, and underprivileged children & families. Please fill out all details accurately and provide verifiable Google Drive documentation.

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Important: Google Drive Document Sharing Instruction

Upload your supporting files (NID/Birth Certificate, Medical Reports/Prescriptions, Academic ID/Fee Slips, Cost Estimates) to Google Drive. Ensure the folder/file link permission is set to:

"Anyone with the link — Viewer" (লিংক পাওয়া যে কেউ দেখতে পারবে)

Applicant / Referrer Information

Your Full Name *

Relationship with Beneficiary *

Mobile Number *

Alternative Mobile Number

Email Address

District *

Upazila / Thana *

Union / Ward / Area

Full Residential Address *

Beneficiary & Child Safeguarding Profile

Beneficiary is a Child / Under 18 Years (শিশু সুরক্ষানীতি প্রযোজ্য) Child identity and direct contact information are never published publicly to ensure child safeguarding.

Beneficiary Full Real Name *

Public Display Alias (ছদ্মনাম / প্রকাশ্য নাম)

Age / Date of Birth *

Gender *

School / College / Institution

Class / Grade / Year

Guardian / Father Name

Monthly Family Income (BDT)

NID / Birth Certificate No

Assistance Category & Circumstances

Primary Category *

Urgency Level *

Case Headline / Title *

Short Summary (সংক্ষিপ্ত বিবরণ) *

Detailed Story & Need Description *

Financial Breakdown & Cost Estimation

Total Estimated Cost (BDT) *

Already Arranged / Available (BDT)

Requested Public Assistance (BDT) *

Estimated Deadline / Target Date

Hospital / School / Vendor Details

Supporting Documentation & Google Drive Links

Add Google Drive links for each required document category. Ensure permission is "Anyone with link - Viewer".

Document Type

Google Drive Link *

Description / Note

Document Type

Google Drive Link

Description / Note

Consent & Verification Declaration

I declare that all information and documentation provided are true and accurate to the best of my knowledge. I give consent to Nirmol Bangladesh to verify documents and conduct field/remote interviews with the beneficiary/family/institution. I consent to the publication of the verified case summary under safeguarded alias on the Nirmol Bangladesh public portal for fundraising purposes.