\documentclass[12pt]{article}

\usepackage[T1]{fontenc}

\textwidth 132mm
\textheight 230mm
\oddsidemargin 18mm
\evensidemargin \oddsidemargin
\topmargin -10mm
\parskip\medskipamount
\parindent0pt
\pagestyle{empty}

\begin{document}

\begin{tabular}{@{}l}
Helsinki University of Technology\\
Department of Computer Science and Engineering\\
Laboratory for Theoretical Computer Science
\end{tabular}

\vspace{5mm}

{\bfseries T-79.189 Student Project in Theoretical Computer Science} (3 cr)

\vspace{5mm}

\begin{tabular}{@{}|ll|}
\hline
                      Title of Work: &
\\
                                     &
\\
                                     &
\\
                                     &
\\
\hline
                             Author: &
\\
                                     &
\\
\hline
                     Student Number: &
\\
                                     &
\\
\hline
                         Department: &
\\
                                     &
\\
\hline
                     Degree Program: &
\\
                                     &
\\
\hline
                            Address: &
\\
                                     &
\\
                                     &
\\
                                     &
\\
\hline
                       Phone Number: &
\\
                                     &
\\
\hline
                     E-Mail Address: &
\\
                                     &
\\
\hline
          Author's Signature:        &
\\
                                     &
\\
\hline
     Date of Submission for Grading: &
\\
                                     &
\\
\hline
                    Date of Grading: &
\\
                                     &
\\
\hline
                              Grade: &
\\
                                     &
\\
\hline
                         Supervisor: &
\\
                                     &
\\
\hline
            Supervisor's Signature: &
\\
                                     &
\\
\hline
                         Instructor: &
\\
                                     &
\\
\hline
             Instructor's Signature: &
\\
                                     &
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
\\
\hline
\end{tabular}

\end{document}
