-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, BLTgpdUl5BND4u/vFif1tI27k7n9fDTKJb3cYIAMxEI/Vhlo3s6ElC6g7Wn092QB 8PyUAcZdIhYrz7476w5MEg== 0000950123-10-104979.txt : 20101112 0000950123-10-104979.hdr.sgml : 20101111 20101112163427 ACCESSION NUMBER: 0000950123-10-104979 CONFORMED SUBMISSION TYPE: S-1/A PUBLIC DOCUMENT COUNT: 3 FILED AS OF DATE: 20101112 DATE AS OF CHANGE: 20101112 FILER: COMPANY DATA: COMPANY CONFORMED NAME: REVA Medical, Inc. CENTRAL INDEX KEY: 0001496268 STANDARD INDUSTRIAL CLASSIFICATION: ORTHOPEDIC, PROSTHETIC & SURGICAL APPLIANCES & SUPPLIES [3842] IRS NUMBER: 330810505 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: S-1/A SEC ACT: 1933 Act SEC FILE NUMBER: 333-168852 FILM NUMBER: 101187191 BUSINESS ADDRESS: STREET 1: 5751 COPLEY DRIVE, SUITE B CITY: SAN DIEGO STATE: CA ZIP: 92111 BUSINESS PHONE: (858) 966-3000 MAIL ADDRESS: STREET 1: 5751 COPLEY DRIVE, SUITE B CITY: SAN DIEGO STATE: CA ZIP: 92111 S-1/A 1 a56782a4sv1za.htm FORM S-1/A sv1za
As filed with the Securities and Exchange Commission on November 12, 2010
 
Registration No. 333-168852
 
UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
 
 
 
 
Amendment No. 4
to
FORM S-1
REGISTRATION STATEMENT UNDER THE SECURITIES ACT OF 1933
 
 
 
 
REVA Medical, Inc.
(Exact name of Registrant as specified in its charter)
 
 
 
 
         
Delaware
  3842   33-0810505
(State or other jurisdiction of
incorporation or organization)
  (Primary Standard Industrial
Classification Code Number)
  (I.R.S. Employer
Identification Number)
 
5751 Copley Drive, Suite B
San Diego, CA 92111
(858) 966-3000
(Address, including zip code, and telephone number, including area code, of Registrant’s principal executive offices)
 
 
 
 
Robert B. Stockman
Chief Executive Officer
5751 Copley Drive, Suite B
San Diego, CA 92111
(858) 966-3000
(Name, address, including zip code, and telephone number, including area code, of agent for service)
 
 
 
 
Copies to:
Michael S. Kagnoff, Esq.
Jeffrey C. Thacker, Esq.
DLA Piper LLP (US)
4365 Executive Drive, Suite 1100
San Diego, California 92121
Tel: (858) 677-1400
Fax: (858) 677-1401
 
 
 
 
Approximate date of commencement of proposed sale to the public:  As soon as practicable after the effective date of this registration statement.
 
If any of the securities being registered on this Form are to be offered on a delayed or continuous basis pursuant to Rule 415 under the Securities Act of 1933, check the following box.  o
 
If this Form is filed to register additional securities for an offering pursuant to Rule 462(b) under the Securities Act, check the following box and list the Securities Act registration statement number of the earlier effective registration statement for the same offering.  o
 
If this Form is a post-effective amendment filed pursuant to Rule 462(c) under the Securities Act, check the following box and list the Securities Act registration statement number of the earlier effective registration statement for the same offering.  o
 
If this Form is a post-effective amendment filed pursuant to Rule 462(d) under the Securities Act, check the following box and list the Securities Act registration statement number of the earlier effective registration statement for the same offering.  o
 
Indicate by check mark whether the registrant is a large accelerated filer, an accelerated filer, a non-accelerated filer, or a smaller reporting company. See the definitions of “large accelerated filer,” “accelerated filer” and “smaller reporting company” in Rule 12b-2 of the Exchange Act. (Check one):
 
             
Large accelerated filer o
  Accelerated filer o   Non-accelerated filer þ   Smaller reporting company o
        (Do not check if a smaller reporting company)    
 
CALCULATION OF REGISTRATION FEE
 
             
 
    Proposed Maximum
   
Title of Each Class of
  Aggregate Offering
  Amount of
Securities to be Registered   Price(1)   Registration Fee
 
 
CHESS Depositary Interests   $ 95,000,000   $  6,774 (2)
Common Stock, $0.0001 par value per share       (3)
 
 
 
(1) Estimated solely for the purpose of calculating the registration fee in accordance with Rule 457(o) under the Securities Act.
 
(2) Previously paid.
 
(3) Pursuant to Rule 457(i), no additional filing fee is payable with respect to the shares of common stock issuable upon conversion of the CHESS Depositary Interests because no additional consideration will be received in connection with the conversion.
 
 
 
 
The Registrant hereby amends this registration statement on such date or dates as may be necessary to delay its effective date until the Registrant shall file a further amendment which specifically states that this registration statement shall thereafter become effective in accordance with Section 8(a) of the Securities Act of 1933 or until the registration statement shall become effective on such date as the Commission, acting pursuant to said Section 8(a), may determine.
 


 

 
EXPLANATORY NOTE
 
This Amendment No. 4 is being filed solely to file Exhibit 10.25 and to update the Exhibit List accordingly.


 

PART II
 
INFORMATION NOT REQUIRED IN PROSPECTUS
 
Item 13.   Other Expenses of Issuance and Distribution.
 
The following table indicates the expenses to be incurred in connection with the offering described in this registration statement, other than placement agent fees, all of which will be paid by us. All of the amounts are estimated except the SEC registration fee.
 
         
    Amount to be paid  
 
SEC registration fee
  $   6,774  
Printing and mailing
    176,000  
Legal fees and expenses
    1,768,000  
Accounting fees and expenses
    850,000  
Transfer agent and registrar
    17,000  
Miscellaneous
    222,226  
         
Total
  $ 3,040,000  
         
 
Item 14.   Indemnification of Directors and Officers.
 
Our amended and restated certificate of incorporation and amended and restated bylaws that will be effective upon completion of the offering provide that each person who was or is made a party or is threatened to be made a party to or is otherwise involved (including, without limitation, as a witness) in any action, suit or proceeding, whether civil, criminal, administrative or investigative, by reason of the fact that he or she is or was one of our directors or officers or is or was serving at our request as a director, officer, or trustee of another corporation, or of a partnership, joint venture, trust or other enterprise, including service with respect to an employee benefit plan, whether the basis of such proceeding is alleged action in an official capacity as a director, officer or trustee or in any other capacity while serving as a director, officer or trustee, shall be indemnified and held harmless by us to the fullest extent authorized by the Delaware General Corporation Law against all expense, liability and loss (including attorneys’ fees, judgments, fines, ERISA excise taxes or penalties and amounts paid in settlement) reasonably incurred or suffered by such.
 
Section 145 of the Delaware General Corporation Law permits a corporation to indemnify any director or officer of the corporation against expenses (including attorneys’ fees), judgments, fines and amounts paid in settlement actually and reasonably incurred in connection with any action, suit or proceeding brought by reason of the fact that such person is or was a director or officer of the corporation, if such person acted in good faith and in a manner that he or she reasonably believed to be in, or not opposed to, the best interests of the corporation, and, with respect to any criminal action or proceeding, if he or she had no reason to believe his or her conduct was unlawful. In a derivative action, or an action brought by or on behalf of the corporation, indemnification may be provided only for expenses actually and reasonably incurred by any director or officer in connection with the defense or settlement of such an action or suit if such person acted in good faith and in a manner that he or she reasonably believed to be in, or not opposed to, the best interests of the corporation, except that no indemnification shall be provided if such person shall have been adjudged to be liable to the corporation, unless and only to the extent that the court in which the action or suit was brought shall determine that the defendant is fairly and reasonably entitled to indemnity for such expenses despite such adjudication of liability.
 
Pursuant to Section 102(b)(7) of the Delaware General Corporation Law, Article 12 of our amended and restated certificate of incorporation eliminates the liability of a director to us or our stockholders for monetary damages for such a breach of fiduciary duty as a director, except for liabilities arising:
 
  •   from any breach of the director’s duty of loyalty to us or our stockholders;
 
  •   from acts or omissions not in good faith or which involve intentional misconduct or a knowing violation of law;
 
  •   under Section 174 of the Delaware General Corporation Law; and
 
  •   from any transaction from which the director derived an improper personal benefit.


II-1


 

 
The foregoing discussion of our amended and restated certificate of incorporation, amended and restated bylaws, indemnification agreements, and Delaware law is not intended to be exhaustive and is qualified in its entirety by such amended and restated certificate of incorporation, amended and restated bylaws, indemnification agreements, or law.
 
Reference is made to Item 17 of our undertakings with respect to liabilities arising under the Securities Act.
 
Item 15.   Recent Sales of Unregistered Securities
 
We have issued the following securities that were not registered under the Securities Act of 1933, as amended, or the Securities Act. The offers, sales and issuances of these securities were deemed to be exempt from registration under the Securities Act in reliance on Section 4(2) of the Securities Act, and/or Regulation D and the other rules and regulations promulgated thereunder, or Rule 701 promulgated under Section 3(b) of the Securities Act as transactions not involving a public offering or transactions under compensatory benefit plans and contracts relating to compensation as provided under such Rule 701. The recipients of securities in each such transaction represented their intention to acquire the securities for investment only and not with a view to or for sale in connection with any distribution thereof and appropriate legends were affixed to the share certificates and warrants issued in such transactions.
 
  •   In May 2007, we issued and sold convertible promissory notes in the aggregate principal amount of $5,000,000 and warrants to purchase an aggregate of 153,692 shares of Series H preferred stock at an exercise price of $6.50 per share to investors in a bridge loan financing transaction completed in a series of closings. In December 2007, these notes, including the approximate $163,830 in accrued interest, were converted into an aggregate of 793,629 shares of our Series H preferred stock. In addition, at the time of the note conversion, we issued warrants to these noteholders to purchase an aggregate of 158,726 shares of our common stock at an exercise price of $6.50 per share.
 
  •   From December 2007 to June 2010, we issued an aggregate of 6,454,986 shares of Series H preferred stock for a purchase price of approximately $6.50 per share and warrants to purchase an aggregate of 1,290,999 shares of our common stock at an exercise price of approximately $6.50 per share to investors in a private placement transaction completed in a series of closings, for aggregate gross proceeds of approximately $42.0 million.
 
  •   In April 2010, we exercised a right of first refusal to acquire an aggregate of 461,071 shares of Series H preferred stock and warrants to purchase an aggregate of 92,214 shares of our common stock for a total purchase price of $550,000 from certain affiliates of Pequot Capital Management. We purchased these shares solely to facilitate their sale to certain of our existing stockholders because we did not have sufficient time to assign our right of first refusal to them and subsequently administered the sale of these securities before expiration of the right of first refusal. Following our purchase, we sold these shares at the same purchase price to certain of our existing stockholders.
 
  •   Prior to and contingent upon the consummation of our offering, we anticipate that (i) our preferred stockholders will convert an aggregate of 14,739,732 shares of our preferred stock into 14,739,732 shares of our common stock; (ii) our warrant holders will exercise preferred and common stock warrants to purchase an aggregate of 701,821 shares of our common stock; (iii) our noteholders will convert notes, with an aggregate of approximately $28,409,000 of principal and accrued interest outstanding as of September 30, 2010, into 5,588,187 shares of our common stock; and (iv) we will issue an aggregate of 868,972 shares of our common stock as cumulative dividends and an aggregate of 189,981 shares of our common stock as an anti-dilution adjustment, to certain of our stockholders.
 
  •   From January 2007 through September 2010, we granted stock options to employees and directors under our 2001 Stock Option Plan pursuant to which the optionees may purchase up to an aggregate of 643,500 shares of common stock (net of cancellations) at a weighted average exercise price of $1.40 per share of our common stock. Each of these options is immediately exercisable.
 
Item 16.   Exhibits and Financial Statement Schedules.
 
(a) See the Exhibit Index on the page immediately preceding the exhibits for a list of exhibits filed as part of this registration statement on Form S-1, which Exhibit Index is incorporated herein by reference.
 
(b) Financial Statement Schedules
 
All other schedules have been omitted because they are not applicable.


II-2


 

Financial Statement Schedules
 
All schedules have been omitted because they are not required or are not applicable or the required information is shown in the financial statements or notes thereto.
 
Item 17.   Undertakings
 
(a) Insofar as indemnification for liabilities arising under the Securities Act may be permitted to directors, officers and controlling persons of the registrant pursuant to the provisions described under Item 14 above, or otherwise, the registrant has been informed that in the opinion of the Securities and Exchange Commission such indemnification is against public policy as expressed in the Securities Act and is therefore unenforceable. In the event that a claim for indemnification against such liabilities (other than the payment by the registrant of expenses incurred or paid by a director, officer or controlling person of the registrant in the successful defense of any action, suit or proceeding) is asserted by such director, officer or controlling person in connection with the securities being registered, the registrant will, unless in the opinion of its counsel the matter has been settled by controlling precedent, submit to a court of appropriate jurisdiction the question whether such indemnification by it is against public policy as expressed in the Securities Act and will be governed by the final adjudication of such issue.
 
(b) The undersigned Registrant hereby undertakes that:
 
(1) For purposes of determining any liability under the Securities Act of 1933, the information omitted from the form of prospectus filed as part of this registration statement in reliance upon Rule 430A and contained in a form of prospectus filed by the registrant pursuant to Rule 424(b)(1) or (4) or 497(h) under the Securities Act shall be deemed to be part of this registration statement as of the time it was declared effective.
 
(2) For the purpose of determining any liability under the Securities Act of 1933, each post-effective amendment that contains a form of prospectus shall be deemed to be a new registration statement relating to the securities offered therein, and the offering of such securities at that time shall be deemed to be the initial bona fide offering thereof.


II-3


 

SIGNATURES
 
Pursuant to the requirements of the Securities Act, the Registrant has duly caused this Amendment No. 4 to the Registration Statement to be signed on its behalf by the undersigned, thereunto duly authorized, in San Diego, California, on November 12, 2010.
 
REVA Medical, Inc.
 
  By: 
/s/  Katrina Thompson
Name:     Katrina Thompson
  Title:  Chief Financial Officer
 
Pursuant to the requirements of the Securities Act of 1933, this registration statement has been signed below by the following persons in the capacities and on the dates indicated below.
 
             
Signature
 
Title
 
Date
 
         
*

Robert B. Stockman
  Chairman of the Board and Chief
Executive Officer (Principal Executive
Officer)
  November 12, 2010
         
/s/  Katrina Thompson

Katrina Thompson
  Chief Financial Officer (Principal
Financial Officer and Principal
Accounting Officer)
  November 12, 2010
         
*

Robert K. Schultz, Ph.D.
  President and Chief Operating Officer   November 12, 2010
         
*

Brian Dovey
  Director   November 12, 2010
         
*

Anne Keating
  Director   November 12, 2010
         
*

Gordon E. Nye
  Director   November 12, 2010
         

James J. Schiro
  Director   November 12, 2010
         
*

Robert Thomas
  Director   November 12, 2010
             
*By:  
/s/  Katrina Thompson

Katrina Thompson
Attorney-in-fact
       


II-4


 

INDEX TO EXHIBITS
 
         
Exhibit
   
Number
 
Description of Exhibits
 
  3 .1   Certificate of Incorporation.*
  3 .2   Amendment to Certificate of Incorporation to be effective upon completion of the offering.*
  3 .3   Amended and Restated Certificate of Incorporation to be effective upon completion of this offering.*
  3 .4   Bylaws.*
  3 .5   Amended and Restated Bylaws to be effective upon completion of this offering.*
  4 .1   Form of Stock Certificate.*
  4 .2   Form of Amended and Restated Investors’ Rights Agreement, by and among REVA Medical, Inc. and the holders of our preferred stock set forth therein.*
  5 .1   Opinion of DLA Piper LLP (US) regarding the legality of the securities being registered.*
  10 .1   Telecom Business Center Business Lease between FSP Telecom Business Center Limited Partnership and REVA Medical, Inc. dated December 18, 2001.*
  10 .2   First Amendment to Telecom Business Center Business Lease between FSP Telecom Business Center Limited Partnership and REVA Medical, Inc. dated January 3, 2005.*
  10 .3   Second Amendment to Telecom Business Center Business Lease between ARI Commercial Properties, Inc. and REVA Medical, Inc. dated February 18, 2006.*
  10 .4   Third Amendment to Telecom Business Center Business Lease between ARI Commercial Properties, Inc. and REVA Medical, Inc. dated December 14, 2006.*
  10 .5   Fourth Amendment to Telecom Business Center Business Lease between ARI Commercial Properties, Inc. and REVA Medical, Inc. dated May 7, 2008.*
  10 .6   Agreement and Plan of Merger, dated October 13, 2004, by and among REVA Medical, Inc., Boston Scientific Corporation, RMI Acquisition Corp. and certain stockholder representatives set forth therein.*
  10 .7   Amendment No. 1 to the Agreement and Plan of Merger, dated December 7, 2007, by and among REVA Medical, Inc., Boston Scientific Corporation, RMI Acquisition Corp. and certain stockholder representatives set forth therein.*
  10 .8   Securities Purchase Agreement between Boston Scientific Corporation and REVA Medical, Inc. dated October 13, 2004.*
  10 .9   Amendment No. 1 to Securities Purchase Agreement between Boston Scientific Corporation and REVA Medical, Inc. dated December 7, 2007.*
  10 .10   Distribution Option Agreement, dated December 7, 2007, by and between REVA Medical, Inc. and Boston Scientific Corporation.*
  10 .11   Exclusive License Agreement Number between Rutgers, The State University of New Jersey and REVA Medical, Inc. dated July 1, 2010.++*
  10 .12   Royalty and License Agreement between Integra/LifeSciences Corporation and REVA Medical, Inc. dated February 2, 2004.++*
  10 .13   2001 Stock Option/Stock Issuance Plan.+*
  10 .14   Form of Stock Option Agreement.+*
  10 .15   Form of Addendum to Stock Option Agreement.+*
  10 .16   2010 Equity Incentive Plan.+*
  10 .17   Form of Stock Option Agreement.+*
  10 .18   Form of Stock Option Agreement entered into with Robert Thomas and Anne Keating.+*
  10 .19   Form of Director and Officer Indemnification Agreement.+*
  10 .20   Employment Agreement, dated July 1, 2010, by and between REVA Medical, Inc. and Robert B. Stockman.+*
  10 .21   Employment Agreement, dated October 21, 2010, by and between REVA Medical, Inc. and Robert Schultz.+*
  10 .22   Employment Agreement, dated October 21, 2010, by and between REVA Medical, Inc. and Katrina Thompson.+*
  10 .23   Form of Offer Management Agreement between REVA Medical, Inc. and Inteq Limited.*
  10 .24   Form of CDI Subscription Application for non U.S. investors.*
  10 .25   Form of CDI Subscription Application for U.S. investors.
  10 .26   Form of Escrow Deed between REVA Medical, Inc. and Computershare Investor Services Pty Limited.*
  21 .1   List of Subsidiaries.*
  23 .1   Consent of Ernst & Young LLP, Independent Registered Public Accounting Firm.*
  23 .2   Consent of DLA Piper LLP (US) (included in Exhibit 5.1).*
  24 .1   Powers of Attorney (included in the signature page).*
  99 .1   Section 13 of the ASX Settlement Rules.*
 
+ Management Compensation Plan
 
++ Confidential Treatment Request
 
* Previously filed
 
** To be filed by Amendment


II-5

EX-10.25 2 a56782a4exv10w25.htm EX-10.25 exv10w25
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>      
             

 

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