exv10w23






Exhibit 10.23












Application Form



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
[XX Month 2010] consisting of [XX] pages, carefully
before completing this Application Form. To meet the
requirements of the Corporations Act, this
Application Form must not be distributed to another
person unless included in, or accompanied by, the
Prospectus dated [XX Month 2010]. A person who gives
another person access to this Application Form must,
at the same time and by the same means, give the
other person access to the Prospectus. The Company
will send you a free paper copy of the Prospectus if
you have received an electronic prospectus and you
ask for a paper copy before the Prospectus expires on
[insert date] 2011.














	 
	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 Postcode







	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Unit	 	Street Number	 	Street Name or PO Box /Other Information
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 

	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 

	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 	 
	 







	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	City / Suburb / Town	State	 	Postcode	 
	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 

	 	 

	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 





	 	 	 
	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 note that funds are unable to be directly debited from your bank
account




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	G
	 	Drawer	 	 	 	 	Cheque/Bank Draft Number	 	 	 	 	BSB Number	 	 	 	 	Account Number	 	 	 	 	Amount of Cheque/Bank Draft	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 




Make your cheque or bank draft payable to “REVA Medical — Offer”





	1)	 	By submitting this Application Form and applying for CDIs, I/we declare that this
application is completed and lodged according to the Prospectus 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. I/we agree to be bound by the Bylaws and
Certificate of Incorporation of the Company.
	 
	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.




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 [XX Month] 2010 issued by the
Company and the US prospectus dated [XX Month] 2010 contained in the
Registration Statement. This Application Form is included in the Prospectus. 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, the
US prospectus, any supplementary documents and the Application Form, free of charge on request if
you contact the REVA Offer Information Line on 1800 197 827 (from within Australia) or +61 3 9938
4372 (from outside Australia). Australian and New Zealand investors should not rely on any
information which is not contained in the Prospectus in making a decision as to whether to
acquire securities in the Company under the Offer.





	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
	 
	 	 	Make your cheque or bank draft payable to “REVA Medical — Offer” in Australian currency and
cross it Not Negotiable. Your cheque or bank draft must be drawn on an Australian Bank.
	 
	 	 	 	Complete the cheque details in the boxes provided. The total amount must agree with the amount
shown in box B. Please note that funds are unable to be directly debited from your bank account.
	 
	 	 	 	Cheques will be processed on the day of receipt and as such, sufficient cleared funds must be held
in your account as cheques returned unpaid may not be re-presented and may result in your
Application being rejected. Paperclip (do not staple) your cheque(s)
to the Application Form where indicated. Cash will not be accepted. Receipt for payment
will not be forwarded.














By returning this Application Form with your Application Monies, you agree to these statements.
I/We:





	•	 	have read the Prospectus in full;
	•	 	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 in consultation with the
Lead Manager in their absolute discretion;
	•	 	authorise the Lead Manager and 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;
	•	 	agree to be bound by the By-laws and Certificate of Incorporation of the Company;
	•	 	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; and
	•	 	represent, warrant and agree that I/we have not received the Prospectus outside Australia and
am/are not acting on behalf of a person resident outside Australia unless the CDIs may be
offered in my/our jurisdiction without contravention of the security laws of the jurisdiction
or any need to register the Prospectus, the CDIs or the Offer.










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, 6 December 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)




Note that ONLY legal entities are allowed to hold CDIs. 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>