\documentclass[11pt,a4paper%
,pdftex%
]{article}
\usepackage{times}
\usepackage{graphics}
\pagestyle{empty}


% ****************************************************************************
% ****************************************************************************


\date{}

% ****************************************************************************
% ****************************************************************************

\begin{document}
\thispagestyle{empty}
\vspace*{-3cm}
\begin{minipage}{5cm}
  \begin{center}
%\hbox to 0pt
{\includegraphics{../bitmaps/dmtcs}}\\
    Discrete
    Mathematics \\ \& \\
    Theoretical Computer Science
\end{center}
\end{minipage}\hfil {\huge Copyright Transfer}\\

\thispagestyle{empty}

\bigskip
\bigskip
\vfil

% ****************************************************************************
% ****************************************************************************

\noindent
{\large\bf Author(s):} 

\vfill
\noindent
\hbox to \textwidth{\hrulefill}

\vfil
\noindent
{\large\bf Title of the paper:} 

\vfill
\noindent
\hbox to \textwidth{\hrulefill}

\vfil
\noindent
{\large\bf Title of the conference:} 


\vfill
\noindent
\hbox to \textwidth{\hrulefill}

\vfil
\footnotetext[1]{Please rule out if not applicable.}
\noindent

I hereby transfer to the {\it Discrete Mathematics and Theoretical
    Computer Science}, DMTCS, non profit organization constitued under
  French law, all the rights concerning the conference paper herein
  mentionned.  I confirm, that my co-authors\footnotemark[1]{} and
  their employer(s)\footnotemark[1]{} agreed on this step.
  
  I confirm that the following clauses are part of this agreement:

  \begin{itemize}
  \item The authors keep the right to reuse any portion of the work,
    without fee, in future works of their own provided that the DMTCS
    citation are properly included.
    
  \item DMTCS guarantees free access to the paper on the internet.
  \item Copyright falls back to the authors in case the internet
    service of DMTCS can not be continued.
  
    
  \item The authors, as anybody else, \emph{for non-profit use only}
    have the right to copy the electronic version of the paper
    \textbf{as it is on the server of DMTCS} and to distribute it
    freely in its electronic form.
\end{itemize}

\bigskip
\bigskip
\bigskip

\noindent
{\large\bf Date:} \hbox to 30mm{\hrulefill}\hfil{\large\bf Address:}

\bigskip
\bigskip
\noindent
{\large\bf Signature:}

\bigskip
\bigskip
\noindent
\medskip
\noindent
\hbox to 50 mm{\hrulefill}

\vfill

\noindent
\hbox to \textwidth{\hrulefill}

\noindent
{\small \textit{Discrete Mathematics and Theoretical Computer Science} (DMTCS)\\
62, rue du Cardinal Mathieu\\
F-54000 Nancy -- France
}

\end{document}