Broker Code Adviser Code

Exhibit 10.25

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

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

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 ***@***

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>