Exhibit G – Sample Contract RFQ 2435-860Professional Service Contract • May 30th, 2025 • Washington
PROFESSIONAL SERVICE CONTRACT DDDS Consultative Medical Examinations DSHS Contract Number:2535-60179Resulting From Procurement Number: This Contract is between the state of Washington Department of Socialand Health Services (DSHS) and the Contractor identified below, and is governed by chapter 39.29 RCW. Program Contract Number: Contractor Contract Number: CONTRACTOR NAMEGrant K. Jones CONTRACTOR doing business as (DBA)Jones, Grant K. CONTRACTOR ADDRESS1234 Hampton Court SW Olalla, WA 98333-3333 WASHINGTON UNIFORM BUSINESS IDENTIFIER (UBI) DSHS INDEX NUMBER 146184 CONTRACTOR CONTACTGrant Jones CONTRACTOR TELEPHONE(360) 555-1212 CONTRACTOR FAX CONTRACTOR E-MAIL ADDRESSgrant@email.com DSHS ADMINISTRATIONEconomic Services Administration DSHS DIVISIONDivision of Disability Determination Services DSHS CONTRACT CODE3724PP-35 DSHS CONTACT NAME AND TITLE DSHS CONTACT ADDRESS DSHS CONTACT TELEPHONE DSHS CONTACT FAX DSHS CONTACT E-MAIL ADDRESS IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF