Form TC 94-169 at a glance
What it is: Kentucky Transportation Cabinet, Division of Driver Licensing, form TC 94-169, Commercial Driver License Self-Certification.
Who signs: Under SIGN, write your Print Name, then your Signature and the Date on the lines.
A filled-in Form TC 94-169 example: a CDL holder drives in Kentucky and other states
How to fill out Form TC 94-169, box by box
Your NAME, SSN, DLN, DOB, PHONE and EMAIL
Enter your NAME (last), (first) and (MI), SSN, DLN, DOB, PHONE and EMAIL.
Your driving category
Kentucky requires all CDL holders to be medically certified (601 KAR 1:005) regardless of category selected, while FMCSA only requires medical certification for drivers operating in non-excepted, interstate operations.
Select only one of the four categories.
Non-excepted interstate: by signing you certify that you operate or expect to operate in Kentucky and other states (interstate commerce).
Excepted interstate: by signing you certify that you operate or expect to operate in Kentucky and other states (interstate commerce) but, engage exclusively in transportation or operations excepted under 49 CFR 390.3(f), 391.2, 391.68, or 398.3 from all or parts of the qualification requirements of 49 CFR part 391.
Non-excepted intrastate: by signing you certify that you operate or expect to operate in Kentucky only (intrastate commerce). This category requires a "K" restriction to be printed on your CDL/permit.
Excepted intrastate: by signing you certify that you operate or expect to operate in Kentucky only (intrastate commerce) but, engage in transportation or operations excepted from all or parts of the State driver qualifications requirements. All Kentucky CDL applicants/holders must be medically certified. Therefore, no CDL holder/applicant is excepted intrastate and should never mark this category.
If you answered yes to one or more of the activities on the form as the only operation in which you drive, you operate in excepted interstate commerce; if you answered no to all of them, you operate in non-excepted interstate commerce.
If you operate in both excepted interstate commerce and non-excepted interstate commerce, you must choose non-excepted interstate commerce to be qualified to operate in both types of interstate commerce.
Most CDL holders who drive CMVs in interstate commerce are non-excepted interstate commerce drivers.
You operate in non-excepted intrastate commerce when you drive a CMV only in intrastate commerce and are required to meet your State of licensure's medical certification requirements.
Print Name, Signature and Date
Under SIGN, write your Print Name, then your Signature and the Date on the lines.
More rules for Form TC 94-169
The Federal Motor Carriers Safety Regulations require all CDL holders to self-certify as to what type driving he/she performs or expects to perform.
Sources
[1] Form TC 94-169 (05/2017), Commercial Driver License Self-Certification, Kentucky Transportation Cabinet (the Official source link on this page).