Application Form (U.S. Investors Only)

by REVA Medical, Inc.
November 12th, 2010
Exhibit 10.25
(PIN LOGO)

Application Form (U.S. Investors Only)
This Application Form is important. If you are in doubt as to how to deal with it, please contact your stockbroker or professional adviser without delay. You should read the entire Prospectus dated 12 November 2010 consisting of 168 pages, carefully before completing this Application Form.
 
Registry Use Only
 
 


                                                                       
Broker Code       Adviser Code
 
 
                                                                   
 
 
         

                                                         
     


A   I/we apply for (Insert Number of CDIs)
 
 
 

                                                     
 
B   I/we lodge full Application Money
 
 
 

                                                                 
 


Number of CDIs in REVA Medical, Inc (Company) at A$1.10 per CDI. Each CDI represents one-tenth of a share of common stock in the Company.
Note: Minimum of 2,000 CDIs (A$2,200, equivalent to 200 Shares) to be applied for, and thereafter in multiples of 1,000 CDIs (A$1,100, equivalent to 100 Shares)
     
C  
Individual/Joint applications — refer to naming standards overleaf for correct forms of registrable title(s)
                                                                                                                                                           
Title or Company Name Given Name(s)       Surname
 
 
                                                                                                                                                       
 
 
   

                                                                                                                                                   
 
                                                                                                                                                           
Joint Applicant 2 or Account Designation                                      
 
 
                                                                                                                                                       
 
 
                                                                                           

                                                           
 
                                                                                                                                                           
Joint Applicant 3 or Account Designation                                      
 
 
                                                                                                                                                       
 
 
                                                                                           

                                                           
 
     
D  
Enter your postal address — Include State and Zipcode
                                                                                                                                                           
Unit   Street Number   Street Name or PO Box /Other Information
 
 
                                                                                                                                                       
 
 
                                                                                           

                                                           
 
                                                                                                                                                           
 
 
                                                                                                                                                       
 
 
                                                                                           

                                                           
 
                                                                                                                                                     
City / Suburb / Town State   Zip Code  
 
 
                                                                                                                                                 
 
 
   

                                                                                                                                             
         
     
E  
Enter your contact details
                                                                                                                                                           
Contact Name           Telephone Number — Business Hours / After Hours
 
 
                                                                                           

                                                           
     
Email Address
                                                                                                                                                           
 
 
 

                                                                                                                                                     
 
     
F  
CHESS Participant
Holder Identification Number (HIN)
                                                                 
 
 
             

                                               
 
Please note that if you supply a CHESS HIN but the name and address details on your form do not correspond exactly with the registration details held at CHESS, your application will be deemed to be made without the CHESS HIN, and any securities issued as a result of the Offer will be held on the Issuer Sponsored subregister.


Payment details – Please transfer funds to the following account:
                                                
G
  Drawer         Cheque/Bank Draft Number   BSB Number       Account Number         Amount of Cheque/Bank Draft  
 
                                           
 
     

                                     
                   
1)   By submitting this Application Form and applying for CDIs, I/we declare that this application is completed and the declarations/ statements on the reverse of this Application Form and I/we declare that all details and statements made by me/us (including the declaration on the reverse of this Application Form) are complete and accurate.
 
2)   I/We enclose my/our cheque and/or bank draft for an amount shown being payment at A$1.10 per CDI (each CDI equivalent to one-tenth of a Share or A$11.00 per Share), and understand that no interest will be paid on Application Monies.
 
    By completing this Application Form and applying for CDIs, I/we declare that I/we have received a print out of the Prospectus dated 12 November 2010 contained in the Registration Statement.
See back of form for completion guidelines


 

How to complete this form

Please complete all relevant white sections of the Application Form in BLOCK LETTERS, using black or blue ink. These instructions are cross referenced to each section of the form.
The CDIs to which the Application Form relates are CDIs over Shares in the Company. Further details about the CDIs are contained in the Prospectus dated 12 November 2010 contained in the Registration Statement. The Prospectus contains important information about investing in CDIs.
You should read the Prospectus before applying for CDIs. The Company will send paper copies of the Prospectus, any supplementary documents and the Application Form, free of charge on request if you contact the REVA Offer Information Line on +61 3 9938 4372 (from outside Australia).
A     CDIs Applied for
 
    Enter the number of CDIs you wish to apply for. The application must be for a minimum of 2,000 CDIs (equivalent to 200 Shares) (A$2,200) and in multiples of 1,000 CDIs (equivalent to 100 Shares) (A$1,100) thereafter. You may be issued all of the CDIs applied for or a lessor number. The issue price is A$1.10 per CDI.
 
B     Application Monies
    Enter the amount of Application Monies. To calculate the amount, multiply the number of CDIs by the A$1.10 per CDI offer price. Please make sure the amount of your cheque and/or bank draft equals this amount.
 
C     Applicant Name(s)
    Enter the full name you wish to appear on the holding statement for your CDIs. This must be either your own name or the name of a company. Up to 3 joint Applicants may register. You should refer to the table below for the correct forms of registrable title. Applications using the wrong form of names may be rejected. Clearing House Electronic Subregister System (CHESS) participants should complete their name identically to that presently registered in the CHESS system.
D     Postal Address
    Enter your postal address for all correspondence. All communications to you from the Company and the Registry will be mailed to the person(s) and address as shown. For joint Applicants, only one address can be entered.
 
E     Contact Details
    Enter your contact details. These are not compulsory but will assist us if we need to contact you.
 
F     CHESS
 
    REVA Medical, Inc (the Company) will apply to the ASX to participate in CHESS, operated by ASX Settlement Pty Limited, a wholly owned subsidiary of Australian Securities Exchange Limited. In CHESS, the company will operate an electronic CHESS Subregister of security holdings and an electronic Issuer Sponsored Subregister of security holdings. Together the two Subregisters will make up the Company’s principal register of securities. The Company will not be issuing certificates to applicants in respect of CDIs allotted. If you are a CHESS participant (or are sponsored by a CHESS participant) and you wish to hold CDIs allotted to you under this Application on the CHESS Subregister, enter your CHESS HIN. Otherwise,
leave this section blank and on allotment, you will be sponsored by the Company and allocated a Securityholder Reference Number (SRN).
 
G     Payment
 
    All Application monies should be paid in Australian currency. Please transfer funds to the REVA Medical — Offer account, details are on the first page of this Application Form.


By returning this Application Form with your Application Monies, you agree to these statements. I/We:
  have completed the Application Form accurately and completely;
  acknowledge that once the Company accepts my/our Application, I/we may not withdraw it;
  apply for the number of CDIs that I/we apply for (or a lower number allocated in a way allowed under the Prospectus);
  acknowledge that my/our Application may be rejected by the Company;
  authorise the Company and their respective officers or agents, to do anything on my/our behalf necessary (including the completion and execution of documents) for the CDIs to be allocated to me/us;
  am/are over 18 years of age; and
  acknowledge that neither the Company nor any person or entity guarantees any particular rate of return on the CDIs, nor do they guarantee the repayment of capital.


Lodgement of Application
Application Forms must be received by Computershare Investor Services Pty Limited (“CIS”) Melbourne by no later than 5:00PM (AEDT) on Monday, December 6, 2010. You should allow sufficient time for this to occur. Return the Application Form with cheque(s) attached to:
Computershare Investor Services Pty Limited
GPO Box 7115
SYDNEY NSW 2001
Neither CIS nor the Company accepts any responsibility if you lodge the Application Form at any other address or by any other means.
Privacy Statement
Personal information is collected on this form by Computershare Investor Services Pty Limited (“CIS”), as registrar for securities issuers (“the issuer”), for the purpose of maintaining registers of securityholders, facilitating distribution payments and other corporate actions and communications. Your personal information may be disclosed to our related bodies corporate, to external service companies such as print or mail service providers, or as otherwise required or permitted by law. If you would like details of your personal information held by CIS, or you would like to correct information that is inaccurate, incorrect or out of date, please contact CIS. In accordance with the Corporations Act 2001, you may be sent material (including marketing material) approved by the issuer in addition to general corporate communications. You may elect not to receive marketing material by contacting CIS. You can contact CIS using the details provided on the front of this form or e-mail privacy@computershare.com.au
If you have any enquiries concerning your Application, please contact Computershare Investor Services Pty Limited on 1800 197 827.
Correct forms of registrable title(s)
Applications must be made in the name(s) of natural persons, companies or other legal entities in accordance with the Corporations Act. At least one full given name and the surname is required for each natural person. The name of the beneficial owner or any other registrable name may be included by way of an account designation if completed exactly as described in the examples of correct forms of registrable title(s) below.
             
             
Type of Investor     Correct Form of Registration     Incorrect Form of Registration
             
       
Individual
    Mr John Alfred Smith     J.A Smith
- Use given name(s) in full, not initials
           
             
       
Joint
    Mr John Alfred Smith &     John Alfred &
- Use given name(s) in full, not initials
    Mrs Janet Marie Smith     Janet Marie Smith
             
       
Company
    ABC Pty Ltd     ABC P/L
- Use company title, not abbreviations
          ABC Co
             
Trusts
           
- Use trustee(s) personal name(s)
    Ms Penny Smith     Penny Smith Family Trust
- Do not use the name of the trust
    <Penny Smith Family A/C>      
             
Deceased Estates
           
- Use executor(s) personal name(s)
    Mr Michael Smith     Estate of Late John Smith
- Do not use the name of the deceased
    <Est John Smith A/C>      
             
       
Minor (a person under the age of 18)
    Mr John Alfred Smith     Peter Smith
- Use the name of a responsible adult with an appropriate designation
    <Peter Smith A/C>      
             
Partnerships
    Mr John Smith &      
- Use partners personal name(s)
    Mr Michael Smith     John Smith & Son
- Do not use the name of the partnership
    <John Smith & Son A/C>      
             
Clubs/Unincorporated Bodies/Business Names
           
- Use office bearer(s) personal name(s)
    Mrs Janet Smith     ABC Tennis Association
- Do not use the name of the club etc
    <ABC Tennis Association A/C>      
             
Superannuation Funds
           
- Use the name of trustee of the fund
    John Smith Pty Ltd     John Smith Pty Ltd Superannuation Fund
- Do not use the name of the fund
    <Super Fund A/C>